DC Metro Area Medical Malpractice Law Blog

According to a recent study of more than 800,000 seniors, patients receiving care from a geriatrician are much more likely to have safe and positive prescription drug outcomes than those receiving care from non-geriatrician specialists or general practitioners.  The study appears in the latest issue of the journal Medical Care, an official journal of the American Public Health Association.

The Agency for Healthcare Research and Quality (AHRQ), a division of the U.S. Department of Health and Human Services (HHS), recently issued a 10-item advisory for hospitals and healthcare facilities designed to improve patient safety and reduce medical errors.  Though AHRQ primarily supports research designed to assist health administrators and medical personnel, this knowledge of best practices in patient safety can also benefit the public by enabling patients and their families to advocate for safer medical care.  Following are the 10 recommendations, re-posted in their entirety:

According to a recent report from the Centers for Disease Control and Prevention (CDC), it appears that more people in the United State now die from Methicillin-resistant Staphylococcus aureus (MRSA) than from Acquired Immune Deficiency Syndrome (AIDS). MRSA, which is typically hospital acquired, or nosocomial, was responsible for an estimated 94,000 life-threatening infections and 18,650 deaths in 2005, while, in that same year, approximately 16,000 deaths were attributable to AIDS. The report is set forth in the October 17, 2007 issue of The Journal of the American Medical Association (JAMA).

Common acid reflux and ulcer drugs appear to cause cognitive impairment in older African-American adults, according to a new study in the Journal of the American Geriatrics Society.  Histamine 2 receptor antagonist (H2A) drugs -- more commonly known as acid blockers -- are among the most frequently prescribed drugs in the U.S., and some varieties are also available without prescription.  Axid, Pepcid, Tagament and Zantac are a few examples.  A five-year observational study of more than 1,500 African-American seniors, however, has indicated that the drugs might be responsible for the significant cognitive decline of almost one-fifth of the study participants.  Data from the study suggests older African-American patients are 2.5 times as likely to suffer cognitive impairment if they use the drugs on a long-term basis.  Conducted by Indiana University School of Medicine and the Regenstrief Institute, the study demonstrates the need for further research into the safety and efficacy of these drugs for all patients. 

Older adults with cataracts or age-related macular degeneration (ARMD) are more likely to suffer an early death, according to new study published in the Archives of Ophthalmology.  Cataracts involve a clouding of the lens of the eye, and ARMD is a gradual deterioration of the back of the retina. 

The rate of infection of Clostridium difficile (C. diff.) more than doubled between 1993 and 2003, according to a new study published in the journal Archives of Surgery.  According to researchers, serious C. diff. infections, which often accompany prolonged antibiotic use, are becoming more prevalent in hospitals and nursing homes.  In 1993, the C. diff. death rate was 20.3 deaths per 100,000 cases.  By 2003, it had risen to 50.2 deaths per 100,000.  The number of surgeries performed to contain the damage of C. diff. also tripled in that same length of time; when untreated infection damages the colon, segments of the intestine have to be surgically removed. 

Eye exams may help predict dementia in seniors, according to research published in Stroke, the journal of the American Heart Association.  Researchers say the presence of retinopathy (damaged retinas) in older patients is a sign of early damage to blood vessels in the brain, and has been known to indicate that the patient is more likely than others to suffer a stroke.  This latest study controlled for variables other than retinopathy, then compared the cognitive status of patients.  Findings suggest that in senior patients with high blood pressure, a diagnosis of retinopathy doubled the odds that he or she would develop dementia.  No such relationship exists in patients with normal blood pressure.

Oral health and physical well-being are closely related in senior citizens, according to the World Health Organization (WHO).  Reduced mobility often makes it harder for older adults to maintain their oral health, and the resulting dental complications then can lead to poor nutrition.  That poor nutrition contributes to lower overall health, they warn.  Beyond this, complicated regimens of prescription drugs can also affect the oral health of seniors.  A common side effect of many drugs, for instance, is dry mouth, and a perpetually dry mouth poses hazards such as susceptibility to fungal infections.

A non-profit federation of long-term care facilities recently applauded the efforts of two lawmakers for introducing bipartisan legislation to mandate automatic fire sprinkler systems in long-term care facilities. 

Eye exams are a part of comprehensive medical care.  Withholding them from nursing home patients constitutes neglect.  A new study published in the Archives of Ophthalmology shows that despite this fact, many residents are going without this essential care.  The study was conducted in 17 Alabama nursing homes and involved nearly 400 residents.  Results demonstrated that two-thirds of patients had no reference to eye exams listed in their medical charts, despite the fact that 90% had adequate health insurance coverage.  Researchers believe that long-term care staff may view concerns regarding sight as relatively unimportant in residents with medical conditions such as dementia.

Methicillin-resistant Staphylococcus aureus (MRSA) is almost ten times more prevalent in the U.S. than had been suspected by health officials.  The finding is part of a first-ever nationwide study of the super-infection published by the Association for Professionals in Infection Control and Epidemiology (APIC).  In their survey of more than 1,000 hospitals covering all 50 states, researchers found that 46 of every 1,000 U.S. patients are infected or colonized with MRSA -- a national rate of nearly 5%.  As many as 1.2 million patients could be infected each year.  Another unexpected finding in the study is that the intensive care areas of medical facilities are not necessarily the most prone to infection -- a finding with profound implications not only for hospitals, but also for long-term care settings such as nursing homes.  Authors of the study point out that transmission of the organism is preventable, and hope that the report serves as a wake-up call for hospitals and patients alike.  

A report issued by the Institute of Medicine, stated that 1.5 million Americans are negatively affected by mistakes in the prescribing and administration of medication. The report suggests that implementation of electronic prescribing programs which are capable of cross checking  the myriad of factors that can determine a patient’s reaction to a drug will decrease those negative outcomes. Furthermore, the report recommends measures to increase the amount of drug information accessible to the public.  Most importantly, the report called for an enhanced dialog between patient and physician in order educate patients regarding to their medications. 

A bill in the U.S. Senate would provide more federal oversight of crimes against elders who rely on a healthcare provider. The Elder Justice Act of 2006 would create a variety of programs, including:

• an Office of Elder Justice in the Department of Health and Human Services
• an Office of Elder Justice in the Department of Justice
• a federal database of data collected nationally regarding elder abuse
• reporting crimes in federally funded nursing homes and other facilities

Summary of the Senate Bill

District of Columbia’s Adult Protective Services

Virginia’s Adult Protective Services

Maryland Elder Abuse Resources

Patients are almost 70 percent less likely overall to die in a top-tier hospital as they are in a bottom-tier one, according to a recent comprehensive HealthGrades study of Medicare patients aged 65 and older undergoing certain emergency procedures. HealthGrades is a healthcare-ratings firm, with data from 2003-05.

Meanwhile, in 2005, there was only one geriatric medicine specialist for every 5,000 Americans over age 65, and only nine out of the nation’s 145 medical schools offered a department of geriatrics, according to a recent article in the New York Times.

In a recent statement by Dr. William Plested, III, the president of the American Medical Association, he  warns that a cut to Medicare reimbursements, proposed by Congress, will send even more doctors away from the specialty.

On December 12, 2006, the Institute for Healthcare Improvement (IHI) announced a national campaign intended to dramatically reduce the incidents of medical harm in healthcare institutions in the United States.  The 5 Million Lives Campaign, if successful, would be "the biggest improvement in patient safety in the history of modern health care" according to Donald Berwick, MD, MPP, President and CEO of IHI.  The campaign will focus on matters such as the adoption of various improvements in care that can save lives and prevent injuries, such as decubitus ulcers (bed sores), surgical complications and infections.

The average national cost for Class 1 nursing home care rose 1.5 percent over last year, to $206 per day for a private room, according MetLife’s 2006 survey of nursing home and home healthcare costs. The cost for a semi-private room rose by almost four percent, to $183 per day.

Average costs for private and semiprivate rooms, respectively, for local regions surveyed included:

DC: $260, $247

Silver Spring, MD: $220, $189

Baltimore, MD: $220, $192

Northern Virginia: $251, $208

A new study in Nursing Forum found that while nursing home staff are aware of almost all medication errors, just five percent of those errors are ever reported to the facility's management.

The study also found that preventable errors are the eighth most common cause of death.  Medication errors may contribute to a large percentage of these preventable deaths because elderly patients are often frail and especially susceptible to changes in their medications.

If you or a family member believes that you have a case involving nursing home negligence, please contact us on-line at Regan Zambri & Long or call us at 202-463-3030 for a free consultation.  If you would like to receive our complimentary electronic newsletter, please click here.

The Centers for Medicare and Medicaid Services, the federal agency that regulates nursing home safety, has proposed a rule that would require all nursing homes to install sprinkler systems.

If you or a family member believe that you have a case involving nursing home negligence, please contact us on-line at Regan Zambri & Long or call us at 202-463-3030 for a free consultation.  If you would like to receive our complimentary electronic newsletter, please click here.  

According to a recent study and surveys conducted by Consumer Reports, “not-for-profit nursing homes generally provide better quality of care for residents than for-profit facilities.”

According to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) , hospitals and nursing homes need to reconcile each patient's current medication orders with the medications the patient has been taking in order to prevent potentially fatal errors.  Reconciliation must be done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions.

According to the JCAHO Sentinel Event Alert, reconciliation should be done at every transition of care. Transitions in care include changes in setting, service, practitioner or level of care. The process includes five steps:  1) make a list of current medications; 2) make a list of medications to be prescribed; 3) compare the two lists; 4) make clinical decisions based on the comparison; and 5) communicate the new list to the providers and to the patient.   Communication seems to be the key to patient safety.

A pharmacy at one hospital reported a reduction in potential adverse drug events of 80 percent when they required detailed medication histories for all patients scheduled for surgery.

You might be interested to learn that the Joint Commission's sentinel event database includes more than 350 medication errors resulting in death or major injury. JCAHO believes half of those could have been avoided through effective medication reconciliation. Approximately, 63 percent involved problems with communication among providers.

The Institute for Safe Medication Practices (ISMP) has received many reports of medication reconciliation errors.  Please click on ISMP above to review their Medication Safety Alert newsletter of April 21, 2005, which includes a sampling of such errors that resulted from failed communication.

Ask your doctor or nursing home administrator whether their facility has implemented this critical safety procedure.

Consumers understand the importance of being informed and working with their medical providers in a partnership to obtain the best medical care. Patient Advocacy Resources is a guide to assist consumers in locating resources for a variety of topics. A partial listing of topics and links includes:

• seeking cancer treatment,
• making informed medical decisions,
• questions to ask before having surgery,
  
• medical record management requirements,
• disability rights laws,
• guide to choosing health care,
• guide to community and online support groups.

Consumer Reports has released a guide to nursing homes. The report highlights the top ten percent and the bottom ten percent of homes in each state based on staffing levels, deficiencies cited in the past three state reports, and quality indicators (such as proportion of those who were at risk for various maladies to those who actually had them). Twelve of the homes have been on the bottom ten list every year since 2000. 

Consumer Reports offers the general advice that not-for-profit homes typically provide the best care, and that independent homes are typically better run than those in a chain. When selecting a home, be sure to check out the state report, which, by law must be on “readily accessible” in the lobby.

Patients, especially seniors, often split tablets when tablets are of a higher strength than the patient needs.  The tablets are broken in half, or even quarters, to provide the correct dose. This is often done to reduce costs, since the higher strength tablet sometimes costs about the same as the lower strength one. In some cases the nursing home or hospital may not stock the lower strength of a particular medication. In other cases the patient may not be able to swallow a whole tablet.   The Institute for Safe Medical Practices (ISMP) has recently published information about this issue.

However, tablet splitting can lead to medication errors. If the patient is splitting the tablets at home, he or she can become confused about the dose. Patients often forget to split their tablets, or they can split them again after they've been pre-split in the pharmacy. Some patients may not have the visual acuity or motor skill to do the splitting properly. Even when split well, the pieces can crumble or be uneven in size.

Pharmacists have also made errors because of the way the prescription is written.    When the prescription is written as "1/2 tablet," the pharmacist can confuse this with "1-2 tablets".  This  type of error could lead to a fourfold overdose.

ISMP suggests several ways to prevent errors with tablet splitting:

"• Be sure that the tablet in question is suitable for splitting. If in doubt, check with the manufacturer.

• Ensure the patient has the understanding, skill and motivation to split the tablets. You may have to enlist a family member or caretaker to do this.

• If the tablets are to be split at home, provide the patient or family with a tablet splitter to improve accuracy.

• For inpatients, the pharmacy staff should dispense the tablets already split, rather than relying on nurses to do this on the floor.

• Prescribers should order the strength in milligrams when possible, to avoid misreading an order for "1/2 tablet" for "1-2 tablets."

Additional Information:

ISMP Medication Safety Alert. Tablet Splitting: Do it only if you "half" to and then do it safely. May 18, 2006
http://www.ismp.org/Newsletters/acutecare/articles/20060518.asp

If you are looking for Eldercare Services, you can use the U.S. Administration on Aging Eldercare Services Locator.  These experts will help you locate state and local resources that specialize in care and programs for the elderly. They have a toll free number (1-800-677-1116).  The service is available from 9 a.m. until 8 P.m. (EST) during weekdays.  Spanish speaking assistants are available as well,

The Joint Commission on Accreditation of Healthcare Organizations, commonly known as JCAHO or the Joint Commission, has published its 2007 Assisted Living National Patient Safety Goals.  These patient safety goals apply to all accredited assisted living facilities.

"The 2007 National Patient Safety Goals continue to target critical areas where patient safety can be improved through specific actions in health care organizations,” says Dennis S. O’Leary, M.D., president, Joint Commission.  “Organizations that truly integrate these requirements into their daily operations will realize major opportunities to improve patient safety.”

The annual updating of the National Patient Safety Goals is overseen by an expert panel that includes patient safety experts, as well as nurses, physicians, pharmacists, risk managers and other professionals who have hands-on experience in addressing patient safety issues in assisted living and other health care settings.

The 2007 goals are:

Improve the accuracy of patient identification.

• Use at least two resident identifiers when providing care, treatment or services.  
• Prior to the start of any surgical or invasive procedure, conduct a final verification process, such as a “time out,” to confirm the correct resident, procedure and site, using active—not passive—communication techniques. 

• For verbal or telephone orders or for telephonic reporting of critical test results, verify the complete order or test result by having the person receiving the information record and  “read-back” the complete order or test result.
• Standardize a list of abbreviations, acronyms, symbols, and dose designations that are not to be used throughout the organization.
• Implement a standardized approach to “hand off” communications, including an opportunity to ask and respond to questions.

• Comply with current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines.
• Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a health care-associated infection.

• There is a process for comparing the resident’s current medications with those ordered for the resident while under the care of the organization.
• A complete list of the resident’s medications is communicated to the next provider of service when a resident is referred or transferred to another setting, service, practitioner or level of care within or outside the organization.  The complete list of medications is also provided to the patient on discharge from the facility.
  

• Implement a fall reduction program including an evaluation of the effectiveness of the program.

• Develop and implement a protocol for administration and documentation of the flu vaccine.
• Develop and implement a protocol for administration and documentation of the pneumococcus vaccine.
• Develop and implement a protocol to identify new cases of influenza and to manage an outbreak.
  

Selecting a nursing home for your loved one can be one of the most difficult tasks you will face as an adult.  It can be even more difficult if you are pressed into making a decision.

The American Association of Retired Persons (AARP) has a great checklist for nursing home visits that you can download for free and use.  Most experts recommend visiting at least 3 facilities.  Considering facilities close to you and others who will visit.  Speak with staff, residents and other visitors when you see each facility.   Taste the food being served to the residents and come at different times of day to see what the staffing is like.

As most people know, the Center for Medicare has a website that allows families to compare nursing homes in their region. This site also includes comparisons of nursing homes who participate in medicare, details on nursing home inspections, staffing and other quality measures.  

Here is a brief summary of what other information may be available regarding facilities in DC, MD and VA:

District of Columbia

For nursing homes in the District of Columbia, the D.C. government does not provide nursing home report cards on-line. You can access the information by using the Medicare Nursing Home Compare tool. You can also obtain some information on the District of Columbia on line nursing home directory. For additional questions or concerns about D.C. nursing homes, you can call the District's long-term care ombudsman at 202-434-2140.

Maryland

The Maryland Health Care Commission has a Nursing Home Performance Guide that is a pretty comprehensive resource with facility specific information such as number of beds, resident characteristics and details of deficiencies, if any, found during recent state inspections. You have also call the Maryland long-term care ombudsman office at (410) 767-1091.

Virginia

Virginia does not provide its nursing home report cards on line. However, you can use the Medicare Nursing Home Compare Tool. The Virginia Department of Health's Long Term Care Directory provides a list of licensed nursing homes with contact information. Virginia Health Information (VHI) also offers two nursing home directories. One includes rate information; the other includes bed counts and other financial data. VHI also has a comprehensive long -term care guide.   You can also call the Virginia long-term care ombudsman at (804) 565-1600 and they can also provide numbers for local ombudsmen.

One of the most difficult decisions someone may face is selecting a nursing home facilty for their loved one. There are a number of resources available that aid in the selection. Larry Wheeler, a reporter for USA Today, recommends contacting a hospital discharge planner, social worker, or local agency on aging. The article "Tips on Choosing a Nursing Home" offers suggestions as to questions to ask potential facilities, as well as particular items to investigate.

For the complete article, please click here.