Nursing mistakes kill, injure thousands
Cost-cutting exacts toll on patients, hospital staffs
By Michael J. Berens
Tribune Staff Writer
September 10, 2000
( From the Chicago Tribune Newspaper -USA)First of three parts
Overwhelmed and inadequately trained nurses kill and injure thousands of
patients every year as hospitals sacrifice safety for an improved bottom
line, a Tribune investigation has found.
Since 1995, at least 1,720 hospital patients have been accidentally killed
and 9,584 others injured from the actions or inaction of registered nurses
across the country, who have seen their daily routine radically altered by
cuts in staff and other belt-tightening in U.S. hospitals.
Registered nurses are the primary sentinels of patient care, providing first
warning and rapid intervention for those too sick to help themselves. But
the majority of hospitals in Chicago and nationally are quietly eliminating
or supplanting the role of their best-trained, highest-paid nurses, creating
a harried work environment that often compromises patient welfare.
The Tribune analyzed 3 million state and federal computer records to create
a database that, for the first time, quantifies the hidden role registered
nurses play in medical errors. Because of incomplete reporting in the
medical field, these numbers only hint at the full scope of the problem.
And because of lax disciplinary oversight in most states, including
Illinois, nurses who make errors or have problems such as a drug addiction
rarely receive severe punishment; sometimes they travel to a new state to
practice again.
Lapses in nursing care sometimes have only minor consequences, but many are
fatal:
In Chicago, at Rush-Presbyterian-St, Luke's Medical Center, 2-year-old
Miguel Fernandez received a deadly overdose of sedatives from a newly
graduated nurse who was left alone to perform a delicate medical procedure
without training.
In Denver, Mary Heidenreich, 78, was killed early last year when a nurse,
who reported being overwhelmed with the care of 15 patients, inadvertently
delivered a fatal dose of drugs into an intravenous line.
At a Wichita, Kan., hospital where staff shortages left up to 20 critically
ill patients in the hands of one nurse, patient Deedra Tolson, 38, bled to
death unnoticed after a hysterectomy and 61-year-old Shirley Keck's pleas
for help went unanswered until she suffered permanent brain damage.
Registered nurses-who receive more education and perform more complicated
procedures than licensed practical nurses or nurse aides-outnumber doctors
2-1 in hospitals.
State and national disciplinary records indicate, and researchers agree,
that registered nurses long have been responsible for more patient deaths
and injuries each year than any other health-care professional-largely
because they have more contact with patients. But the errors have
intensified in recent years as working conditions have put more pressure on
nurses.
Although most nurses perform their jobs with distinction, they increasingly
find themselves both victims of hospital mismanagement and perpetrators of
medical errors, forced to walk a thin line between do no harm and doing the
impossible.
"Do you know how afraid I was that I was going to fry somebody?" said Marge
Sampson, 55, a registered nurse who worked two decades at the state's
largest public hospital, the University of Illinois at Chicago Medical
Center, before stress drove her to a medical office job.
"It's so scary to spend eight hours, flying by the seat of your pants and
just praying," she said. "In my day, they taught you never to give a drug
until you looked it up and verified the proper doses. But you can't do that.
There's no time. You're just dumped into this. It's so nightmarish I can't
even explain."
In a marked departure from previous assertions, officials with the American
Hospital Association, the trade group for 5,000 hospitals, acknowledge that
patients are being placed at risk due to inadequate staffing and
insufficient training.
The dramatic changes that have rocked nursing in recent years have come as
managed care programs grew in dominance and federal Medicaid reimbursements
dropped-two trends that are squeezing hospital profit margins as never
before, said Rick Wade, senior vice president for communications at the AHA.
But, the Tribune found, nursing services have been deliberately cut even in
financially thriving hospitals-the result of staff reductions used to
preserve historic profit levels.
AHA President Dick Davidson warned hospital executives nationally in 1996
that the public was beginning to discover the "thinness" of nurse staffing,
according to a copy of a confidential 19-page report obtained by the
Tribune.
Summarizing private survey findings, he wrote, "Patients suffered,
literally, because medications and vital, comforting services were delayed,
confused or forgotten."
To track nursing errors, the Tribune analyzed computerized records from the
U.S. Food and Drug Administration and Health and Human Services Department.
Also examined were federal and state files of annual hospital surveys and
complaint investigations, court and private health-care files, and nurse
disciplinary records from every state.
The Tribune found that, since 1995:
At least 418 patients have been killed and 1,356 others injured by
registered nurses operating infusion pumps, which regulate medicine flow. In
each of these cases the nurse either lacked the training to operate infusion
pumps or claimed to be burdened with too many patients. The pumps can be
misused in several ways, and sometimes nurses punched in the wrong amount of
medicine on the built-in touch pad. In the death of a Texas patient two
years ago, for example, an order for 9.10 milligrams of morphine was entered
as 91.0 milligrams. Calculation errors are so prevalent that some nurses
called them "death by decimal."
To compensate for understaffing, hospitals often rely on machines with
warning alarms to help monitor patients' vital signs. At least 216 patient
deaths and 429 injuries have occurred in hospitals where registered nurses
failed to hear alarms built into lifesaving equipment, such as respirators
and blood-oxygen monitors. At a New York hospital in September last year, a
patient died unnoticed of a heart attack even though a respiratory alarm
sounded. A sole nurse assigned to monitor 10 patients told federal
investigators she did not hear the alarm because she was attending to
another patient in distress.
At least 119 patients have been killed and 564 others injured by unlicensed,
unregulated nurse aides, an additional toll not included in the statistics
for registered nurses. Earning an average of $9 an hour, aides are used to
augment staffing but sometimes supplant higher-paid registered nurses. Up to
one-third of nursing staffs consist of aides, many of whom are not required
to have high school diplomas. Under a cost-saving program in at least two
Chicago hospitals, housekeeping staff assigned to clean rooms have been
pressed into duty as aides to dispense medicine.
Nationally, the number of reported nursing errors within hospitals has
increased in each of the last five years, coinciding with an economic crisis
that has left one of every four hospitals operating in the red, state and
federal records show.
Decades of carefree spending by hospitals came to an abrupt halt in the
mid-1990s, as economic reality set in and managed care changed the landscape
of medicine. Hospitals turned to health-care consultants whose cost-cutting
strategies invariably targeted hospitals' largest expense: nurse staffing.
For patients, this means hospitals staffed entirely by registered nurses as
recently as five years ago are now relying heavily on lesser-trained and
lower-paid practical nurses and aides.
A Tribune survey of the Chicago area's 10 largest hospitals found that
registered nurses now comprise about three-quarters of the staff assigned to
general patient care, a drop mirrored in the majority of hospitals
nationally.
Hospitals across the country regularly blame a shortage of registered nurses
for their staffing deficiencies, but in reality, there is more often a
shortage of nurses willing to work in hospitals.
Deteriorating, oppressive workplace conditions-from mandatory overtime to
stagnant pay-have made hospital jobs less appealing. And other options, both
inside the health-care field and outside it, have enticed nurses to quit
hospitals for less stressful, better paying positions.
Administrators at hospitals with competitive salaries, reasonable hours and
an appealing work environment report little trouble in finding nurses. But
those conditions remain the exception.
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