• E-mail
• Print
• RSS

Double mastectomy victim calls hospital's apology a 'PR ploy CMS introduces performance improvement program as new COP New Alert hints at infection control scrutiny in coming months

Patient Safety Monitor Alert, January 28, 2003

Want to receive articles like this one in your inbox? Subscribe to Patient Safety Monitor Alert!

DOUBLE MASTECTOMY VICTIM CALLS HOSPITAL'S APOLOGY A 'PR' PLOY

What does a hospital do when surgeons remove both healthy breasts of a woman who was mistakenly told she had cancer? Make a public apology--at least that's what United Hospital in St. Paul, MN, did last week after just such an incident occurred. Dr. Daniel Foley, the hospital's medical director, told the Twin Cities' KARE-TV that the hospital had made changes after mistakenly removing Linda McDougal's two healthy breasts, according to CNN.com. Hopefully, the changes will ensure "this kind of mix-up would never happen again," said Foley.

But McDougal called the apology a "public relations" ploy that came only after she approached the media with her story, according to the Pioneer Press. McDougal said that after a dark spot appeared on her mammogram last May, her doctor had a biopsy performed, and she was later diagnosed with cancer. Though she never became ill or felt a lump, she was told her only chances for survival were a double mastectomy, chemotherapy, and radiation.

But two days after she had both her breasts removed, her doctor told her she had discovered that a mistake in the hospital's laboratory had caused tissue from McDougal's biopsy to be switched with tissue from another woman.

McDougal has told her story on a number of national television programs such as the "Today" show and "Good Morning America," according to the Pioneer Press. She has not yet decided whether to sue for malpractice, CNN.com reports.

CMS INTRODUCES PERFORMANCE IMPROVEMENT PROGRAM AS NEW COP

If your hospital doesn't already have a data-driven quality assessment and performance improvement program (QAPI), you better get moving. The Centers for Medicare & Medicaid Services (CMS) announced last week that it had adopted a new Conditions of Participation (COP) that requires hospitals to develop and maintain such a program. The purpose of the new COP is for hospitals to proactively improve patient care and performance, according to the CMS final rule.

Hospitals already accredited by the JCAHO can rest a bit easier. CMS acknowledges that JCAHO standards mirror the new COP. "Their standards require hospitals to collect data to monitor performance of processes that involve risks or may result in sentinel events," the final rule says. "Similarly, (Tag 482.21) requires hospitals to consider prevalence and severity of identified problems and to give priority to improvement activities that affect clinical outcomes." However, the new program does extend the current COP to hold medical staff accountable to the governing body for monitoring quality care to an organization-wide function, says Steve Bryant, practice director of accreditation and regulatory compliance for The Greeley Company, a division of HCPro.

All hospitals that participate in Medicare and Medicaid must comply with the new COP (Tag 482.21), regardless of their accreditation status. The new rule takes effect March 25, 2003.

Go to Federal Register to find the final rule in the Federal Register. A Fax Express further examining the new COP has been delivered to subscribers to Briefings on Patient Safety and other HCPro newsletters. Go to Briefings on Patient Safety for more information.

NEW ALERT HINTS AT INFECTION CONTROL SCRUITINY IN COMING MONTHS

Health care organizations should treat all deaths and major permanent losses of function related to nosocomial infections as sentinel events, according to a Sentinel Event Alert released by the Joint Commission last week. Organizations should also comply with hand hygiene guidelines published by the Centers for Disease Control and Prevention (CDC) published last fall, according to the Alert. The guidelines recommend using alcohol-based handrubs along with soap and water and sterile gloves.

The Joint Commission also plans to appoint a new infection control panel of experts to review its infection control standards and survey process, it announced in the release.

The new Alert comes in the wake of a Chicago Tribune article, which last fall alleged that tens of thousands of nosocomial-infection related deaths go unreported. The article also suggested that the JCAHO sometimes fails to ensure safety in hospitals. The CDC estimates that about 90,000 people die annually from preventable infections acquired in the hospital.

Want to receive articles like this one in your inbox? Subscribe to Patient Safety Monitor Alert!

• E-mail to a Colleague
• Print
• RSS
• Archive