      The State
      Columbia, South Carolina
      Mon, Jun. 17, 2002

Medical errors kill, injure S.C. patients

By JOHN MONK
Staff Writer

Prominent Columbia businessman Bob Andrews obeyed doctor's orders last October, took new pills after he'd taken his usual heart medicine and - within hours - dropped dead.

Patients are cautioned against taking Viscicol and Quinaglute together, according to the Physicians Desk Reference. The two drugs can cause heart complications, including sudden death.

Richland County Coroner Gary Watts found Andrews' death was caused by a drug interaction. He ruled it an accident after his investigator located a doctor's order saying the 69-year-old Andrews should take both medicines.

Mistakes by doctors, nurses, pharmacies and hospital staffs kill and injure South Carolinians each year. Insurance figures indicate medical errors kill at least 30 people a year. Many others are injured, some severely, according to the hundreds of payouts made last year by three state-sponsored insurance funds.

The exact number of accidental deaths and injuries is a secret. Hospitals, state agencies, insurance groups and doctors don't want that information public, fearing lawsuits.

But others say awareness of mistakes would help educate the public about medical dangers and increase accountability in the medical profession.

Experts say the public has no idea of just how common deadly errors and accidents are.

"What you know about is just the tip of a huge iceberg," said Dr. Sandra Conradi, a former Charleston County medical examiner, former Medical University of South Carolina professor and a national expert on causes of death.

An inquiry into S.C. patient safety by The State found:

• Deadly errors can happen anywhere, including in the best hospitals, and to anyone, including doctors and nurses when they are patients. Errors range from surgical tools being left inside patients to medicine mixups. Many errors result from haste or carelessness, according to medical officials and lawsuits.

• The state insurance system that compensates most victims is at risk of being overwhelmed by the cost of medical errors. To pay the rising number of victims, many doctors' malpractice insurance rates have been sharply increased. For instance, effective June 1, a heart surgeon's insurance increased to $24,267 a year from $19,303.

• Lawsuits against doctors and hospitals are increasing. Judges and jurors, alarmed at medical mistakes, are speaking out. Last year, for example, an Oconee County jury awarded an injured patient $15 million in punitive damages. That award, one of the largest in state history, was made to send a message to the state's medical profession to crack down on incompetent doctors, the jury's foreman said.

• Some medical groups say they are focusing on increasing patient safety. But with no statewide push, experts warn patients to be vigilant when in a hospital.

'SPURTS' OF ACCIDENTS

Medical errors aren't limited by economic class or geography.

The 178-year-old Medical University of South Carolina in Charleston is home to 600 doctors, many of whom teach and do difficult operations on patients referred to MUSC from elsewhere. Many consider it the state's best collection of hospitals.

Since last fall, however, MUSC has paid out $3.8 million to compensate five families for damages from medical errors.

MUSC's mistakes included accidentally killing two patients, for which it paid out about $1 million each; causing brain damage in two others, paying out $400,000 and $850,000; and allowing an infection to cause the loss of a leg, for which it paid out $500,000.

MUSC general counsel Joe Good said all the incidents were avoidable - "or a jury would have thought that. ‘.‘.‘. We obviously felt we were in the wrong, at least to some degree."

Accidents and lawsuits seem to "come in spurts," said MUSC's Good.

"When something tragic happens, you find out why it happens, admit your part of the guilt, and you go on - you learn from it," Good said.

Even doctors and nurses are hurt by mistakes when they are patients, lawsuits allege.

Last year, Dr. Christopher Biser, 70, a Murrells Inlet physician, was negligently killed at the Medical University of South Carolina, where he was a patient, according to a lawsuit in Charleston County circuit court. MUSC doctors failed to heed warnings that Dr. Biser had only one working kidney and overloaded that kidney, the suit alleges.

MUSC denies wrongdoing.

In Aiken County, a jury awarded $6.9 million in the 1996 death of a nurse, 37-year-old Marshall Welch. It found Welch was negligently given massive doses of narcotics following an operation. After the S.C. Court of Appeals upheld the verdict in 2000, the parties settled.

In Richland County, since last fall, coroner Watts has ruled one other death - besides Andrews' - an accident. In that case, Noland Hopkins, 39, died of unchecked internal bleeding after kidney surgery at Palmetto Health Baptist
An autopsy and pathologist's report found Hopkins bled to death after the operation. "Internal hemorrhage secondary to complications (of surgery)," the coroner's report said.

An autopsy showed Hopkins lost 1.5 liters of blood internally, about one-third the blood in his body, Watts said. He said the blood loss was slow and should have been detected by blood pressure and pulse monitors.

If the hospital had properly monitored Hopkins, he wouldn't have died, the coroner concluded. His report listed the cause of death as "Accident."

A Palmetto Baptist spokeswoman declined comment, saying patient matters are confidential.

Watts said both Andrews' and Hopkins' deaths were, in his judgment, preventable accidents. No lawsuit has been filed in either case.

WHY ERRORS HAPPEN

Mistakes take many forms.

"There is a whole range of 'accidents' involving medical care, from those accidents in which an unexpected and unpredictable event occurs ‘.‘.‘. to out and out bad judgments on the part of a physician or medical caregiver resulting in injury or death," said Conradi, Charleston's former medical examiner.

Experts say only a few of the state's 7,000 doctors are substandard physicians, committing multiple errors. But even good doctors can have a rare bad day.

"I don't think anybody in my profession would say that even the best doctors are error free," said Dr. Ray Greenberg, MUSC's president. "They are human."

It's the same with the state's 50,000 nurses.

"Show me a nurse who says she's never made an error, and I'll show you a liar," said Colleton Medical Center chief executive Rebecca Brewer, leader of a state hospital task force on patient safety and a former nurse.

But, said Brewer, analyses show most mistakes are system errors as opposed to people errors.

"Just a simple thing, like giving one pill. How many opportunities are there for an error before it gets to the patient?" Brewer said, adding nearly all errors are unintentional. "There's no one who goes into medicine and wakes up and says, 'Today, I'm going to take a shortcut that puts a patient at risk.'"

But mistakes happen.

In 1996, when Columbian Nadine Jackson had an operation at Baptist Medical Center, now Palmetto Health Baptist, someone left a 12-inch metal surgical tool in her abdomen.

Usually, operating room teams count surgical tools before closing a patient's incision. In Jackson's case, whatever procedure was used didn't work.

After returning to her job at the S.C. Department of Mental Health, Jackson suffered great pain.

Doctors said it was gas.

"Finally, one day I could stand it no longer and left work and went to the emergency room," Jackson said. Technicians took X-rays and found the object.

In 1999, a Richland County jury awarded Jackson $400,000. The hospital appealed. In 2000, she settled for $250,000

Jackson is lucky. She's still alive.

Frederick DeVoe isn't.

In late 1998, when DeVoe was admitted to MUSC's intensive care unit, doctors gave him tests for infections. The tests showed he had an infection.

But the doctors didn't act on the test results, according to attorneys for both MUSC and DeVoe's family. If they had, they would have ordered antibiotics. DeVoe died of the infection.

Last year, MUSC settled the case for $1 million.

MUSC attorney Good said the hospital didn't treat DeVoe as it should and accepted responsibility.

No S.C. medical group studies deadly errors on a statewide basis. The types of errors cited in nationwide studies by medical and business groups include:

• Misdiagnosis, or failing to see classic signs of a life-threatening condition.

• Neglect. Even in hospitals, patients who need constant monitoring can find themselves alone - and die or become brain dead.

• Medication errors. These range from a doctor writing an erroneous prescription to a nurse giving the wrong medicine.

• Defective equipment. Life-support or alarm machines can fail at crucial times.

INSURANCE CRISIS

The number of successful lawsuits and claims against S.C. doctors and hospitals was once a trickle.

Now it's a flood.

"The frequency and severity of malpractice suits is increasing," said S.C. Department of Insurance commissioner Ernst Csiszar.

More patients are suing, winning more and more money.

In 2001, the state's three major insurance carriers paid $57 million to 714 victims of S.C. medical errors - a record amount.

A small part of the $57 million in payments is due to a new effort by insurers to compensate some victims for obvious errors instead of fighting all claims, regardless of merit.

In any case, 2001's $57 million in payments is sharply up from the $15 million paid to 629 victims five years ago.

Payouts to victims have risen so fast that the state's two major medical insurers - the Joint Underwriters Association and the Patients Compensation Fund - are almost in financial crisis, Csiszar said.

The two funds insure about 5,500 of the state's 7,000 doctors and about 80 hospitals and clinics. Together, the two funds have about $50 million in assets.

But, based on actuarial estimates, the funds should have reserves of $200 million to pay for current and expected claims, Csiszar said.

To beef up those reserves, the Underwriting Association and Compensation Fund are increasing the premiums that they charge doctors.

More than 1,000 patients currently are pressing lawsuits and claims against S.C. hospitals and doctors, insurance groups say.

Many of those claims - perhaps half - will be dismissed, statistics say.

Patients win compensation - either through settlements or verdicts - about half the time in South Carolina, according to a Pennsylvania firm that studies jury trends nationwide.

JURORS, JUDGES SPEAK OUT

Jurors and judges are publicly criticizing the medical profession.

Last November, lawyer Chad McGowan of the Anders law firm in Columbia and lawyer Joey Wright of Anderson won one of the biggest verdicts in state history. The jury returned a judgment of $2.2 million in actual damages and $15 million in punitive damages against an Oconee County surgeon.

The jury foreman, Jana Mize, said she and fellow jurors chose the $15 million figure to get the medical community's attention.

"We wanted to say to the medical profession that we don't want these kinds of people practicing medicine," said Mize.

Evidence at the trial showed Dr. Daniel Vinson's surgery left his patient, Nellie Durham, severely handicapped. Vinson, who has left South Carolina and is no longer licensed here, was unqualified to be doing surgery in the first place, according to allegations in the trial.

Judge Alex Macauley reduced the punitive damages awarded to $8 million. But he wrote Vinson's conduct was "dishonorable, unethical ‘.‘.‘. likely to deceive, defraud, or harm the public."

Macauley said the big verdict was a message to the state's doctors to "monitor the competency (of all doctors)."

Two years ago, 16th Circuit Judge John Hayes of York County raised a jury award to $1.6 million from $1 million in a case where a doctor botched a delivery of a healthy baby boy, Daniel "D.J." Cooke.

Saying the jury's $1 million award "shocks the conscience," Hayes reviewed the case, stressing that D.J. had suffered constant pain from birth injuries before dying at 22 months.

"He never enjoyed any of the innocent childhood pleasures of playing, singing, eating, learning to crawl or taking a step," wrote Hayes, who also noted the devotion of the parents, Daniel and Minnie Cooke, who had tried for years to have a baby. Hayes also knew that most of the jury's original $1 million award was already allotted to medical and legal bills.

In a case decided this spring, the S.C. Supreme Court said a Greenville jury had sent a note, along with its $2.5 million verdict against Greenville Hospital System and Companion Health Care, urging that health organizations be more honest with patients.

Specifically, the jury said, if the doctor is a "resident," an apprentice doctor learning medicine, the patient should be told.

In that case, a resident at a clinic run by the Greenville Hospital System diagnosed a patient, 38-year-old David Dykema, as having viral bronchitis and sent him home to take antibiotics. Dykema had blood clots in the lungs and died, the court said.

SOME REFORMS UNDER WAY

Although no statewide initiative exists, some hospitals and groups are taking steps to improve patient safety.

• The Medical University of South Carolina has begun a safety push, including studying errors and making patients more aware of safety issues.

• Palmetto Health Alliance, which includes Columbia's former Richland and Baptist hospitals, has launched a patient safety and quality initiative. It intends to identify and reduce major errors, put critical care specialists in intensive care units, and monitor doctors' and nurses' performances. It also promises to openly admit to patients and their families when a harmful error has been made.

• The S.C. Hospital Association's patient safety committee has begun a statewide effort to reduce medication errors.

Still, medical experts say, mistakes will happen.

MUSC president Greenberg said: "You've got 4,500 employees, 600 physicians, 30,000 patients running through the system. Errors are going to happen. The question is: 'Do you do everything you can to keep that number as minimal as possible?'"

Greenberg vows MUSC will increase patient safety, making everyone - patients and staff - more aware of the issue.

Some experts suggest patients should be more vigilant.

"I say, 'Never go into a hospital without having someone there as your eyes and ears 24 hours a day,'" said Judith Thompson, executive director of the S
TOLL ON FAMILIES

When medical blunders kill or injure, doctors refer to them as "bad outcomes
Those outcomes can haunt families for decades.

When 8-year-old Elizabeth Grimball of Columbia had a spinal tumor, doctors dismissed her pains as imagination, telling her family the child needed a psychiatrist, said Elizabeth's mother, Leila Grimball.

For three months, doctors denied Elizabeth's problem was physical, even though she had a history of childhood cancer.

The tumor grew. Elizabeth suffered increasing pains radiating from her spine down her legs. She lost her ability to walk, according to a lawsuit.

Doctors continued to insist her complaints were phobia, even vetoing a recommendation by one doctor who wanted a physical test done to rule out a tumor, according to legal papers. Only after Elizabeth had a seizure was a test done. It found the tumor.

Therapy destroyed the tumor. But because of the delay in diagnosis, Elizabeth is paralyzed from the waist down, her mother says.

The Grimballs sued.

For almost two years, the University of South Carolina School of Medicine and Richland Memorial refused to compensate the Grimballs for the huge medical bills expected to follow Elizabeth throughout her life.

Finally, just before trial, the defendants settled. Settlement terms prevent the Grimballs from discussing the dollar amount.

Leila Grimball now works with representatives of the insurance, legal and medical profession to promote settlements of medical error cases without lawsuits.

She is saddened at what happened to Elizabeth but also upset she had to hire a lawyer to fight for compensation that she believes the medical community should have paid in the first place.

"No matter how egregious the error, there's no current way in South Carolina to compensate victims of medical error without legal action," Grimball said
'HE WAS ... MY BEST FRIEND'

When Bob Andrews died last fall, from what Richland coroner Watts said was a preventable medical error, his family was devastated.

"He was my business partner, my best friend - active in every part of my family's life," said son Mike Andrews, 36, his voice breaking. "He was our leader, and it's all been dumped in my lap. I've got awful big shoes to fill."

Coroner Watts said Andrews died from the interaction of two common drugs.

Andrews had been taking daily the heart medication, Quinaglute, to steady his heart.

Then, Andrews got ready to have a colonoscopy - a common procedure to check the bowel for colon cancer. As a prep, Andrews' other doctor prescribed Viscicol -- which can cause complications when mixed with Quinaglute, Watts said
The two drugs together are what killed Andrews, Watts ruled.

The death of Andrews, who owned an auto repair shop near Five Points, was felt beyond his family. It hurt the community.

A noted naturalist, Andrews had promoted Lake Murray so well the Lake Murray Association named him its Citizen of the Year.

The award was given posthumously.

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Posted on Mon, Jun. 17, 2002

-- PREVENTING MEDICAL ERRORS

Medical errors can happen anywhere -- in hospitals, doctors' offices, nursing homes, pharmacies, even your own home. They can involve medicines, surgery, a diagnosis, communication, equipment or laboratory reports. Here are some ways you can help prevent mistakes.

General tips

• Speak up! Medicine is big business. Don't take anyone's attention for granted. Learn all you can about your condition. Ask questions; make a list before a doctor's visit. Write down your course of treatment.

• Get a second opinion if you aren't satisfied with the diagnosis or treatment.

• Consider getting a second opinion from a top health center that specializes in your condition, even if it's out of state. You often can come back to South Carolina for treatment.

• Involve your regular doctor with the specialist. Specialists can get so involved with their field that they lose track of the big picture.

• If you get a test and don't hear back, call for the results. Don't assume no news means everything is OK.

• Insist all relevant tests be done.

In the hospital

• Make sure doctors --including emergency room physicians -- know any allergies or conditions you have, such as diabetes, and any medications you are on. This includes illegal drugs. Doctors need the information to make decisions about your health.

• Have someone with you. This person should be assertive and able to request help from supervisors or on-call physicians if on-duty staff isn't responsive.

• Avoid hospitals on weekends, holidays and nights. Hospitals can be short-staffed at these times.

• Make sure the doctor who is making life-or-death decisions is a veteran doctor. Some hospitals have apprentice doctors, or residents. While licensed, they don't have the judgment or experience of a veteran doctor.

• Before an operation, label the body part to be operated on. Talk with the doctor.

• Choose a hospital where many patients have had the same procedure or surgery you are getting. Studies show hospitals that do many surgeries of a certain type, such as heart bypasses, get better results than those that do fewer.

• Make sure you understand the treatment plan on being discharged from the hospital.

• If someone dies unexpectedly, insist on an autopsy. An autopsy can teach health care officials where they erred, saving other lives. It also can provide peace of mind in assuring that everything that could be done was done.

• You have the right to copies of medical records. However, you may have to pay for copies.

Taking medication

• Make sure you can read the prescription. If you can't, your busy pharmacist may have trouble reading it too.

• Know what the medicine is for, how you take it, when you take it and for how long.

• Know the medicine's side effects and whether it has an adverse reaction with any other medicine you are taking or foods you eat. Mixing some medicines can kill or injure you. Get written information from the pharmacist about your medicine.

• Make sure the medicine the pharmacist gives you is the same as your doctor prescribed.

Resources

Internet resources:

• http://www.ashp.org/patient_safety/links.html; site has links to medical safety sites.

• http://www.qualityforum.org/; site of a national group that wants to develop state-based health care quality measures and reporting.

• http://www.jcaho.org; site for Joint Commission on Accreditation of Healthcare Organizations, including information on patient safety.

Books:

• "Complications," by Dr. Atul Gawande. An inside look by a surgeon at errors and how doctors try to avoid them.

• "Power to the Patient," by Dr. Isadore Rosenfeld. How to know what tests and medications are right for your condition, and when to ask for a second opinion.

SOURCES: S.C. Medical Association, S.C. Hospital Association, VA hospitals, Agency for Healthcare Research and Quality, malpractice lawyers

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Posted on Mon, Jun. 17, 2002

-- MISTAKES AN ISSUE NATIONALLY

Nationwide, deadly medical errors are getting more attention than ever.

"It is simply not acceptable for patients to be harmed by the health care system that is supposed to offer healing and comfort," said a 1999 report by the Institute of Medicine.

Between 44,000 and 98,000 Americans die each year from preventable medical errors, said that landmark study, "To Err is Human: Building a Safer Health System."

Another study put the number of deaths annually due to error far lower -- between 5,000 and 15,000.

Whatever the number, businesses, organizations and groups are taking action.

• The nation's major hospital accreditation group, the Joint Commission on Accreditation of Healthcare Organizations, is making hospitals report how they respond to "sentinel events."

Such events are defined as "unexpected occurrences involving death or serious physical or psychological injury," including "loss of limb or function."

When the commission hears about mistakes, it issues a bulletin to all hospitals warning them to check the potentially unsafe area. This is similar to the Federal Aviation Administration warning about defects in airplanes.

Thus far, the commission's alerts have warned of medication errors, faulty equipment and needle errors.

• More than 90 Fortune 500 corporations have joined The Leapfrog Group initiative. This group will identify hospitals with low error rates and steer their employees to the safe hospitals.

Some efforts are more limited, but practical.

In February, for instance, the American Academy of Orthopaedic Surgeons issued a warning about surgeries on the wrong body part. It urged doctors -- and patients -- to initial the correct operation site before surgery.

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Posted on Mon, Jun. 17, 2002

-- LESSONS LEARNED

No one knows how many medical errors take place, but they are widespread.

• No one is immune; deadly errors happen even to medical professionals when they are patients.

• Medical mistakes can happen anywhere, even at the best hospitals.

• So many patients are suing alleging medical errors by physicians, hospitals or their staff that the state's insurance system for doctors soon may have trouble paying all the victims.

• The size of jury awards to victims of medical errors is increasingors they've seen.

• Health care groups say they are doing more to reduce errors. But experts warn patients to be vigilant.

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Posted on Mon, Jun. 17, 2002

-- MAKING S.C. MEDICINE SAFER

Efforts to make things safer for S.C. patients are in the works. Among them:

• Insurance groups plan a $500,000 program to promote patient safety to new and current doctors.

To be paid for by the state's two major insurance groups -- the Patients Compensation Fund and Joint Underwriters Association -- the program will offer safety seminars for new doctors. Veteran doctors who take the program will get a discount on their malpractice insurance.

Also, an audit team may be sent to veteran doctors' offices to examine procedures and paperwork practices, and make suggestions.

• Doctors who kill or injure patients negligently will pay higher insurance rates to the Compensation Fund and Underwriters Association.

Up to now, doctors who have paid claims to injured patients have paid the same rates as doctors without claims.

• All doctors insured by the two state-sponsored insurers will pay higher insurance rates, in some cases twice as much as now. This will help ensure enough money is on hand to compensate victims of medical errors.

• While saying they always have stressed safety, hospitals across South Carolina are pushing the issue even more.

For instance, the Medical University of South Carolina, which has paid out $3.8 million for five mistakes since October, has a new patient safety administrator. All employees are getting more safety training, and patients will have more information about how to summon veteran doctors or supervisors for help.

• A task force, sponsored by the S.C. Hospital Association, also is trying to develop a plan to reduce medication errors in hospitals. It hopes to establish a way that S.C. hospitals can exchange information -- and heighten awareness -- about all errors that might harm patients.