Reports of hospital mistakes now available online

SALEM, Ore. — At St. Charles Medical Center in Bend, employees failed to notice that a cleaning machine was accidentally reprogrammed to leave out the disinfection cycle. Eighteen patients received colonoscopies with scopes that had been only rinsed with water and alcohol.

At Legacy Emanuel Medical Center in Portland, a nurse accidentally connected a nasogastric tube to oxygen rather than suction. The patient immediately went into cardiac arrest but the nurse did not tell responding physicians about the mistake. The patient was taken to surgery but died two days later of shock and multiple organ failure.

At Salem Hospital, the parents of a 14-month-old child recovering from anesthesia were told the child was “very sleepy.” In fact, the child had stopped breathing and was turning blue. A nurse told investigators that the anesthesiologist had “bagged” the child, or assisted with breathing, for 20 minutes, and that the child had required two doses of Narcon, which is ordered for oversedation, to wake up.

Hospitals make mistakes. When they are reported — by patients, employees or family members — state and federal officials investigate.

Now, for the first time, the U.S. Centers for Medicare and Medicaid (CMS) has released those inspection reports for hospitals nationwide from the past two years. The release was in response to requests from the Association of Health Care Journalists, which has compiled them into a searchable database available to the public.

CMS collects the reports for all hospitals that receive payments from Medicare or Medicaid. That’s all of the hospitals in Oregon except Veterans Administration hospitals.

The database shows that, since January 2011, inspectors have found at least 82 violations during complaint investigations at Oregon hospitals.

The number likely is higher because some reports may not be listed in the database, the association warned. Other inspection dates are noted in the database, but the narrative reports were not provided.

In Oregon, the database is missing two inspection reports from Salem Hospital and one from McKenzie-Willamette Medical Center in Springfield.

The McKenzie-Willamette report, from October 2011, is not available because of a state processing issue, said Dana Selover, manager of the state Healthcare Regulation and Quality Improvement Services division

Salem Hospital provided the newspaper with one of its missing reports, and the Oregon Health Authority provided the other.

Curry General Hospital in Gold Beach had the most violations statewide, with 12 deficiencies found during two inspections in 2011.

Among the problems: Failing to ensure an effective system of patient records; failing to take remedial actions on medication errors; and failing to ensure that there were written, signed orders for drugs and intravenous medications administered to patients.

Curry General Hospital officials did not return a call seeking comment.

Salem Hospital followed, with nine violations found during five inspections.

Three centered on patient rights, two on anesthesia, two on registered nurse supervision of nursing care, one on nursing care plan, and one on staffing and delivery of care.

“We take every one of these seriously,” said Cheryl Nester Wolfe, the hospital’s chief operating officer. “It’s a good opportunity to examine our system and figure out where we can make improvements.”

The hospital provided its plan of correction for three of the investigations. They showed that, after the case of the parents who weren’t told of their child’s troubles recovering from anesthesia, the hospital developed a policy describing the communication process needed when unanticipated outcomes or adverse events occur in children undergoing anesthesia.

“I think that we acknowledge that we could have done a better job with the communication issue,” Wolfe said. “We did work with our anesthesiologist and our staff.”

Statewide, the inspection reports detail problems that were widely publicized, such as medical staff ignoring complaints of sex abuse made against an anesthesiologist at Mid-Columbia Medical Center in The Dalles.

They also describe incidents that likely never made it to public attention:

• At Providence Portland Medical Center, an employee photographed the exposed buttocks of a patient and distributed it by email, along with the caption “pic of a hairy ass.” The employee was dismissed.

• At Legacy Emanuel Medical Center, a surgeon operated on the left eye, rather than the right eye, of a child.

• At Cottage Grove Community Hospital, a physician refused to perform a screening exam on an emergency room patient described as “difficult.”

There are no fines for violations, but the federal government can terminate a hospital’s Medicare agreement if it does not correct problems.

Twelve states already put hospital complaint investigations online. Oregon is not among them.

“We would like to be able to do that,” Selover said. “For us it’s a matter of resources.”

The complaint database also includes links to hospitals’ ratings on Hospital Compare, maintained by Medicare.

They are part of an exploding amount of data becoming available about hospital quality.

Private companies such as Consumer Reports, Healthgrades and U.S. News and World Report also rank hospitals.

In addition to complaint investigations, the CMS requires routine inspections of hospitals every three to four years. The agency does not release those reports.

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