En español l In November 4, 2004, Mary McClinton, a beloved 69-year-old social worker and mother of four, checked into Virginia Mason Medical Center in Seattle for a relatively complex but routine procedure to treat a brain aneurysm. Doctors planned to inject her with a contrast dye to help them guide a stent into her brain, via a catheter in her leg, to repair the aneurysm. Instead, they injected her with an antiseptic — a topical cleaning agent — that had been stored in an unlabeled container on the same tray as the dye. The antiseptic blocked the flow of blood in her leg, which swelled to twice its normal size.
Within hours, McClinton's blood pressure dropped, her kidneys failed and she suffered a stroke. As the toxin coursed through her system, her other organs began to fail as well. Nineteen agonizing days later, surrounded by her grief-stricken family and friends, Mary McClinton died, her son Gerald holding her hand.
Tragically, McClinton's case is far from unique. An estimated 6,000 "never events" — egregious errors like operations on the wrong limb or instruments left inside a surgical wound — occur every month among Medicare patients alone, according to a report from the U.S. Department of Health and Human Services (HHS). The total number of preventable errors is far higher — some studies suggest that up to a third of all hospital admissions result in harm to a patient. And a 2010 study from HHS estimates that 180,000 Medicare beneficiaries die every year from accidents and errors.
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"Preventable hospital errors are a terrible danger to American families and a huge driver of unnecessary health costs," says Leah Binder, president and CEO of The Leapfrog Group, a Washington, D.C.–based nonprofit that assesses hospitals on national standards of safety, quality and efficiency.
To draw attention to the tragic reality of cases like McClinton's, AARP The Magazine has teamed up with Leapfrog to showcase what some of the most innovative hospitals are doing to prevent errors. With its Hospital Safety Score, Leapfrog rates institutions on 26 measures of safety — including "never events," infection rates from IV and catheter lines, secondary infections and hospital-acquired conditions like pressure ulcers and air embolisms — using data it compiles from the Centers for Medicare & Medicaid Services, the American Hospital Association and the Leapfrog Hospital Survey.
One surprising standout: Virginia Mason. In fact, for the past seven years Leapfrog has consistently given the hospital high ratings. Based on the nonprofit's survey, it even named Virginia Mason a top hospital of the decade in 2010. So what was behind the remarkable turnaround? In short, Virginia Mason made becoming the safest hospital in America a top priority.
Even before McClinton's death, it launched an investigation into the error, and later issued public and private apologies to her family. The hospital, which had already started to revamp its safety procedures, redoubled its efforts, systematically implementing new safety protocols across every area of the hospital. Administrators nearly tripled the time that nurses spent at the bedside, instituted checklists before surgeries and established patient safety alerts, which empowered any employee to speak up when a patient's life or health was at risk.
"The hospitals that are transforming health care put patient safety above all," says Lucian Leape, M.D., cofounder of the National Patient Safety Foundation. Of Virginia Mason, he says, "We wish we could clone them."
Read on to learn what Virginia Mason and other superstar hospitals are doing — and what Leapfrog says all hospitals should be doing — to improve patient safety.
About 400,000 drug-related injuries occur each year in hospitals, according to an Institute of Medicine study. To help solve the problem, many of the safest hospitals have embraced the use of a computerized provider order entry (CPOE) system, which forces doctors to enter prescriptions into the computer electronically. "It basically eliminates transcription errors," says Anthony J. Ardire, M.D., senior vice president for quality and patient safety at Lehigh Valley Health Network in Allentown, Pennsylvania.
The system also has built-in safety alerts — for example, it won't allow doctors to prescribe more medicine than is generally recommended. Since implementing the system and introducing bar coding, in which a patient's bracelet is scanned to ensure the right patient is getting the right medication at the right dose, Lehigh Valley's medication-error rate has been reduced from 2 in 100,000 doses to 2 in 1 million doses.
Next page: Infection control. »