Running Head: REPORT ON DEATHS IN US HOSPITALS DUE TO HUMAN ERROR

Dated: (pls insert date)

Ms. Marla J. Weston PhD, RN
Chief Executive Officer
American Nurses Association
8515 Georgia Ave.
Suite 400,Silver Spring, MD 20910-3492
301-628-5000
Dear Ms. Weston,
As you are aware, human error in hospital deaths have become a major proportion of
the total deaths in the Hospitals of our nation, due to which we feel that we cannot
ignore this aspect altogether.
We have therefore compiled a report which shows how we can tackle this menace
jointly i.e. the ANA and the American Public whom we as the NGO AMERICAN
MEDICAL SAFETY represent. You are requested to kindly go through the same,
attached herewith, so that we can hold a tripartite meeting with the ANA, our chief
patron Mrs. Michelle Obama, and our representatives.
We can then and try to circumvent and solve this problem of deaths in US Hospitals due
to human error which has become an albatross round our necks.
Thanking you,

Yours Faithfully
DOROTHY DOGOOD
Executive President
AMERICAN MEDICAL SAFETY

Encl: As above

REPORT ON DEATHS IN US HOSPITALS DUE TO HUMAN ERROR

A REPORT ON
DEATH DUE TO HUMAN ERROR
IN US HOSPITALS

REPORT ON DEATHS IN US HOSPITALS DUE TO HUMAN ERROR

TABLE OF CONTENTS

(i)
(ii)
(iii)
(iv)
(v)
(vi)

Introduction
The facts as they are.
Trends & Accountability
Proposed Solution
Conclusion
References

REPORT ON DEATHS IN US HOSPITALS DUE TO HUMAN ERROR

Introduction
To err is human is an adage we have heard all throughout our lives. The truth of the
same or the imperfection of the human being cannot be denied. However, we have a
duty to try not to err or make foolish mistakes. That is even more true when our
business is in such an industry like healthcare.
Nurses and their role in healthcare have never been appreciated to the extent deserved.
Florence Nightingale and the lady with the lamp image just contributed to this fallacy,
never corrected it. Most of us are unaware that Nightingale founded the first ever theory
of Nursing called the Environment Theory. Nurses interact with the real man or
woman, which lies beneath the faade on the exterior, when the patient is at the most
vulnerable state. The physician sees the patient, prescribes the medicine and leaves
the matter in the hands of the nurse. The nurse has to deal with the patients anger or
denial, passivity or aggressiveness, co-operation or smart aleck behavior.
However, it is seen that a lot of publicity is being given to death in US hospitals due to
human error. We also find that most of these errors are on the part of nurses. In this
small report, we will present our argument that nursing is as vulnerable to pressure as
physicians will and that nurses require breaks at regular intervals to rejuvenate their
bodies and minds.
The facts as they stand
Although human knowledge in Medical Science has increased many folds over what we
knew earlier, if we think over the matter it will not appear so. Whenever we have
conquered and vanquished our enemies at one front, new ones have shown themselves
at other locations.
In this scenario, it makes sense that we have to be winning the war against diseases. In
reality, that is not so.
A few incidents picked at random which occurred at US Hospitals and health care
centers (during the last five years)
1. Hollywood actor Dennis Quaid s twins along with another newly born premature infant
were injected by Heparin, a blood thinning drug, in Cedars Sinai Health Care Centre ,
Los Angeles. The dosage for infants is 100 but the dosage given was 10,000 due to error.
The babies survived after a blood clotting injection was used(The Huffington Post,
21/03/2008)
2. The Methodist hospital in Indianapolis did the same thing in case of six
premature newborn infants. Here, two babies dies and four survived but after a
critical period (Natural News.com; Sept 2006)
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REPORT ON DEATHS IN US HOSPITALS DUE TO HUMAN ERROR

3. Michael Inbar reports that Florida judge Norman E. Bailey underwent surgery for
abdominal pain. Later when his pain did not subside, he was operated again and
a rotting 12x12 surgical sponge was taken out from his stomach which was left
there during the previous surgery.(msn.com; Sept 2010)
4. Rory Staunton, 12 yrs old fell and cut his hand while playing basketball. He had
high fever and was taken to the NYU Langone Medical Centre the next day as he
had developed high fever in the night.
Rory by then had moderate scale
septicemia but he was discharged
from
the hospital. The next day, the 12
year
old died in his house.
What takes the cake here is not that the
doctors could not diagnose Rorys
septicemia, but that the NYU Langone
Medical Center is considered as one of
the
Safest health centers in the US.
(NY Daily News.com, 9th Aug 2012)

NYU Langone Medical Centre

These are just a few of the cuff examples of the unintentional mal practices
taking place in America today, which traumatizes the patient badly, sometimes
even leading to death.

Accountability and Trends

What are the trends of human-error deaths? If we plot them against time, we will
find that there is a small incline which shows that the number of deaths are
increasing. In American Hospitals, the CDC(Center for Disease Control) estimate
that HAIs ( Hospital acquired Infections) brings about 1.7 million infections and
associated deaths to the tune of 99,000 every year .Therefore, we cannot afford to
do nothing and sweep the mess under the carpet hoping that it will disappear on its
own.
What about Accountability? Can we hold the nurses responsible for these maladies
and death? No, we cannot hold the nurses or the doctors responsible. Maybe a little
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REPORT ON DEATHS IN US HOSPITALS DUE TO HUMAN ERROR

for negligence but our objective here is to find a solution to the problem and not to
punish the allegedly guilty in a witch-hunt.
Proposed Solutions
As the authorized representative of the Nurses of America, we propose that the
remedial measures as far as the Nursing fraternity is concerned, are taken by the
ANA. These can be of the following types.
(1) A guidebook, which everyone will be required to comply with and which
shall allocate responsibility on different chairs in the pre and post patient
operation recovery process. The guidebook shall encompass all measures
which is taken now. Should the future bring more advanced nursing
procedures, the guide book can always be updated.
(2) A workshop for 4 days for about 10 senior nursing staff, who will than go
back and impart the same to the junior stall, all being under the supervision
of the ANA.
The resources which shall be required for this can be collected from the
pharmaceutical manufacturing companies . Each company can be a sponsor
or a patron and take financial responsibility of a particular portion of the
remedial measures suggested.
Conclusion
We do not know how successful or how effective the above procedures will
be but one thing is clear. We cannot stay idle waiting for someone else to
bell the cat. The time of reckoning has come and we, the American Medical
Safety, a NGO have stood up first to be counted. We are sure that you will
also join us in our endeavor to make these horror stories exactly what they
are called now, merely- stories.

References:-

REPORT ON DEATHS IN US HOSPITALS DUE TO HUMAN ERROR

The Huffington Post, 21/3/2008, Available at

http://www.huffingtonpost.com/2008/03/21/la-hospital-fined-for-

qua_n_92704.html ; Accessed on 18/08/2012

Natural News, 18/9/2006 , Available at
http://www.naturalnews.com/020447.html Accessed on 18/08/2012

2012 Massachusetts Hospital Association, Inc., n.d..; Patient Care Link,

Healthcare Acquired Infections (HAIs); Available at
://patientcarehttplink.org/improving-patient-care/hospitalacquiredinfections-hai.aspx; Accessed on 18/08/2012