The National Labor Relations Board claims that Holy Family Hospital of Methuen, Massachusetts, part of Steward Health Care System, fired Mary Ramirez for her activity leading a union organizing effort. Ramirez, 61, has 40 years of nursing experience, 18 of them at Holy Family. NLRB also said that nurses at Holy Family weren’t allowed to wear buttons showing support for Ramirez.

Through a spokesperson, Steward has denied the allegations, claiming that Ramirez was fired for a variety of performance issues that were reported to management by a fellow nurse. The hospital claimed that Ramirez intentionally changed a doctor’s order, made an intentional medication error, and didn’t enter a morphine dose in a patient’s record. (Ramirez doesn’t deny that she administered a drug intravenously rather than injecting it, but said it wasn’t an intentional error. She also noted that the patient wasn’t harmed in any way.)

The hospital also said that the Board of Registration put Ramirez on probation for two year for diverting patient medication for her own use. Ramirez didn’t deny the allegation, but again pointed out that no patients were harmed by her actions.

Ramirez maintains that her union activity was the real (and improper) reason for her firing. She’s seeking reinstatement to her position and back pay.

Specifically, doctors who switched from one EHR system to another had an increase in their rate of prescribing errors as measured at three months and one year after adoption. By year two, the prescribing rate had decreased again.

For practices that added new EHR systems saw dramatic improvement in errors rates — in some cases prescribing errors decreased as much as 85%.

Primarily, systems that protect anonymous reporting and don’t emphasize assigning blame for the error get more reports than more traditional reporting systems. That’s the takeaway from a recent report in the journal Pediatrics.

After instituting a new system at a pediatric clinic in North Carolina, the number of mistakes reported increased from an average of five per year to 86.

Under the clinic’s old system, reports weren’t anonymous and frequently led to punishment of some sort for those involved in the error. With the new system, employees were able to report anonymously, and punishments weren’t attached to the error reports. Employees from all areas of the practice were put on a safety team to review reports once a month and find solutions to the reduce the likelihood of a similar mistake happening again.

The most common mistake by far was incorrect data being entered into a patient record, followed by delayed or forgotten lab work and medication errors. About 75% of the mistake reports were addressed by the team with simple procedural changes and staff training.

Timothy Harvey, 51, went to the emergency room at the Mayo Regional Hospital in Dover-Foxcroft, Maine, with what appeared to be a severe allergic reaction.

He was administered 0.3 mg of epinephrine, and his symptoms subsided. When they reappeared, he was given a second dose. Shortly afterward, he collapsed and died. Subsequent investigation showed the second dose was actually 10 times the normal amount.

Unlike the more typical circling-the-wagons reaction, the hospital spoke to the press about the mistake, admitting fault, expressing sympathy to Harvey’s family and outlining its efforts to prevent a similar mistake from occurring again. In response, a member of the state Department of Health and Human Services publicly commended Mayo Regional for how it handled the case.

Of course, it’s easier said than done to admit that a staffer, or you yourself, accidentally killed a patient. People reasonably fear litigation, professional discipline and the family’s reaction. But a handful of studies have shown that health care providers who immediately own up to the mistake actually face fewer lawsuits.

According to the study, patient deaths from medication errors spike 10% above normal rates each July — and only in counties with teaching hospitals. And the death rate increases proportionally with the number of teaching hospitals in the county.

The study’s authors recommend hospitals re-evaluate the responsibilities given to new residents, increase supervision and make an effort to improve education regarding medication safety.

The study was done by researchers from the University of California San Diego, who looked at more than 68 million death certificates issued in the U.S. between 1979 and 2006. They eventually focused on deaths due to medication errors.

The study found no similar spike in summertime deaths outside of a hospital, or deaths from other causes within hospitals.

The study was published in the Journal of General Internal Medicine.

Despite hospitals’ best efforts, the data indicates that some of the most serious adverse events patients can face are becoming more common, not less.

Many so-called “never” events, such as bedsores, retention of foreign objects in a patient and even sexual assault are on the rise, according to a recent review of reported incidents in California over the past few years.

In the 2008-2009 fiscal year, state hospitals saw a 100% increase in “wrong-patient” surgeries, a 78% increase in bedsores and a shocking 131% increase in sexual assaults.

Other never-events saw modest decreases, including wrong-site surgery (down 10%) and death or serious disability due to medication errors (down 6%).

Some of those increases may be due to better reporting of adverse effects. But the numbers indicate there’s still a long way to go in reducing the risks patients face once they’re admitted to the hospital.

Solutions that have worked to bring down the number of adverse events at some hospitals include:

• pre- and post-surgery checklists to triple-check basics such as the patient’s identity, removal of all surgical implements, etc.
• staff training for recognizing/reporting assaults
• using sponges and other surgical implements that have small metallic strips in them that will show up on X-rays for faster identification if left in a patient
• improved labeling for medications to make it easier to distinguish different names, concentrations, etc.

What else can hospitals do to reduce the number of adverse effects? Share your thoughts in the comments.

Reported events Jan.1 through Sept. 30, 2009:

• Wrong-site surgery — 126
• Unintended retention of foreign body — 97
• Delay in treatment — 94
• Operative/Post-op complications — 79
• Suicide — 72
• Patient fall — 65
• Medication error — 34
• Assault, rape or homicide — 27
• Perinatal death or loss of function — 26
• Patient death or injury in restraints — 9

Since JCAHO started tracking sentinel events in ’95, more than 6,500 patients have been affected, with 68% of the events resulting in death.