Medical Errors: Identification and Prevention
State of Florida Mandatory Training

Medical Errors in the State of Florida



Introduction

Defining Medical Errors

What Have We Learned Since the First IOM Report on Medical Errors

Medical Errors in the State of Florida

Intervention: Preventing Medical Errors

Conclusion

Appendix A

Appendix B

References

Test

Exit to Menu



In the Third Annual Patient Safety in American Hospitals Survey (2006), the state of Florida ranked 13th among the 50 states and the District of Columbia in overall patient safety. It was ranked as one of the top 15 states that performed statistically significantly better than expected.

Florida health officials have been collecting data on medical mistakes from hospitals and walk-in surgery centers since 2001. The reports do not include hospital names; they identify aggregate data only. Despite the good ranking that Florida received in the Third Annual Patient Safety in American Hospital Survey (2006), data collected by Florida officials indicate that more than 1,000 patients died in Florida hospitals from adverse events between January 2001 and June 2004. Additionally, nearly 400 patients have needed surgery to remove a sponge or other object left inside them in a prior operation (Gaul, Washington Post, 2005).

Several high profile cases of medical errors have occurred in the State of Florida in recent years.

Surgeon: wrong surgery, wrong site

In April, 2006 a Tampa hand surgeon received a $20,000 fine and temporary suspension from practice on charges she operated on the wrong body part of a patient. This was this surgeon's third mistake of this nature in five years. The Florida Board of Medicine reported that less-severe punishment the first two times did not have the desired effect.

In the most recent case the surgeon was operating at the surgery center in September 2004. She was to repair a young woman's injured middle finger, but made the incision in her ring finger, according to state health department. When she discovered the error, the records say, she closed the incision and performed the operation on the correct finger.

In August 2000, while operating on a 77-year-old man at University Community Hospital, the surgeon mistakenly operated on his left ring finger instead of thumb, records show. The medical board fined the physician $10,000 and ordered her to give a lecture to the hospital staff on how to avoid such errors.

In an operation on a 38-year-old man in 2001, the surgeon operated on the correct hand, but performed the wrong procedure, the records say. In December 2002, she was fined $15,000, ordered to take a course on reducing risks, donate 25 hours of community service and write an article on the perils of wrong procedures, in addition to another lecture.

Tampa Tribune, April 8, 2006; Doctor Fined, Suspended for Errors in Surgery, by Carol Gentry

Pharmacy Misfills Prescriptions

In Florida, a national drugstore misfilled a prescription for Cardura with Coumadin causing the death of a healthy man. It is unclear how the pharmacist provided the customer with a container of Coumadin erroneously labeled "Cardura." What is clear is that the customer took the wrong medication for more than two weeks before he suddenly developed an uncontrollable "bleed" that resulted in a brain hemorrhage from which he never recovered.

What is also becoming clear is that precisely the same error has occurred in the State of Florida on more than this one occasion. And, that the same national drugstore has misfilled numerous other prescriptions throughout the United States.

www.voiceoftheinjured.com

Misdiagnosis Leads to Unnecessary Surgery

In January, 1998 J.H. had a lung removed due to lung cancer. For a year following the surgery, J.H. had multiple follow-up appointments with the surgeons and other healthcare providers. For a year he and his family continued to worry about the possibility of recurrence or spread of the cancer.

One year after the surgery J.H. learned that the pathology report from a biopsy taken during his surgery indicated that he did not have cancer at all. For a year no one told him. CNN, May 1, 2000.

Retrieved April 29, 2006 from http://archives.cnn.com/2000/HEALTH/04/28/thin.white/index.html

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