How a hospital contributed to the deaths of five children


#1

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#2

That was horrible. Perhaps hospitals should have in house laundry? Although that wouldn’t have helped because they were transporting dirty and clean linens on the same carts. How stupid are these administrators? Or corrupt? They likely picked the service because it was he cheapest they could find. Shouldn’t the carts be sanitized?


#3

Seems to me like the main problem here was that the hospital wasn’t training its housekeeping staff properly. If anybody needs to know about hospital hygienic routines it’s them, and somebody decided it wasn’t necessary to teach them. Or just forgot that they were around as long as the surfaces looked clean and the bins were emptied.

Also, nobody thought to check the laundry facilities or routinely sterilize sheets for immune compromised patients? Seems pretty obvious to me.


#4

It’s amazing to me that people are continually amazed that “…a hospital contributed to the deaths of five children”
This happens all the time (over 1000+ times per day). It is no secret. Here is but one study

A study in the Sept. 2013 issue of the ‘Journal of Patient Safety’ said that between 210,000 and 440,000 patients each year who go to the hospital for care suffer some type of preventable harm that contributes to their death. (http://journals.lww.com/journalpatientsafety/Fulltext/2013/09000/A_New,_Evidence_based_Estimate_of_Patient_Harms.2.aspx)

NOTE: the above is an edited quote from NPR: http://www.npr.org/blogs/health/2013/09/20/224507654/how-many-die-from-medical-mistakes-in-u-s-hospitals


#5

Hospitals routinely ignore the most basic scientific evidence concerning cleanliness.

They started installing stainless steel fixtures by preference without doing any sort of research cultures first, and most of them are still installing stainless steel door handles today, despite it being well understood that stainless steel handles are a major conduit of hospital born illnesses.


#6

I often wonder how much “cleanliness theatre” there is, like security theatre - there solely to provide an illusion. Stainless steel door plates and surfaces -look- clean to the eye and modern, whereas brass often looks a bit shabby and worn - the point being that brass autosterilizes itself of most bacteria. The same is true of hand sanitizer - yes, hand hygiene is important, but if you apply sterilizer and go back to thumbing that 2007 ER waiting room copy of People (omg Bennifer back together!) you are not coming out ahead.

I recently saw an EMR pitched with the option of a Patient Information Kiosk - have your patients check in through a terminal in the waiting room. Touchscreen and everything! Wow so modern. What outbreak?


#7

No, it isn’t a secret that patients come to harm in hospitals. I find it a testament to human resiliency that the numbers aren’t even worse…

The Journal of Patient Safety report details the complexity of not only delivering safe care, but how hard it is to quantify errors (a good read -link appreciated). This, in particular, stood out as a way forward:

Needed changes involve not only doctors and hospitals but increased
participation by patients in their health-care decisions. Perhaps it is
time for a national patient bill of rights for hospitalized patients
that would empower them to be thoroughly integrated into their care so
that they can take the lead in reducing their risk of serious harm and
death.15
All evidence points to the need for much more patient involvement in
identifying harmful events and participating in rigorous follow-up
investigations to identify root causes

It is nothing less than a cultural revolution in healthcare that is needed. Much important progress has been made since “To Err is Human” came out. Clearly, much more needs to be done.

On a general note: Strong opinions and outrage are valid and important --these infections should not have happened --and those feelings should fuel a call to action. To which I offer this: As a veteran of Root Cause Analyses, I’ll attest to the fact that the obvious reason isn’t always the right (or only) factor impacting why things go sideways. Be wary of feel-good fixes that assuage guilt and assign blame. The end goal --to make change that keeps a bad outcome from happening again --is not well-served when the drivers are bias and emotion.


#8

Why is it amazing that people are horrified? The hospitals see these studies too, they are ground zero of impact in real life, and yet they continue, after all these years, to neglect the most basic methods of prevention. OVER and OVER. And then THEY are surprised when something arises that causes death based on their own malpractice.


#9

In health care safety is all about connecting dots. You can’t connect hidden dots. That is why transparency is key. Biggest barrier to safety is blame culture and culture of secrecy. Apportioning blame between housekeeping and laundry services is an interesting dynamic but not conducive to improved outcomes. It creates a culture in which being doing things right is more important than doing the right thing. Collaboration is key!


#10

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