The Register's Editorial

Chuck Engholm arrived at the emergency room at Genesis Medical Center on Nov. 9, 2014, complaining of nausea.

Engholm was 63 years old and a long-time resident of Davenport’s Handicapped Development Center, a group home where he was known for his love of horses and cowboys, and where he worked as a sander in the facility’s workshop.

At Genesis, a caregiver from the center told the hospital staff Engholm had been vomiting and there was an odor to it, which doctors later acknowledged pointed to a bowel obstruction. Engholm had a known history of bowel obstructions and just two months earlier had undergone surgery for such an obstruction.

The nurse practitioner who examined Engholm gave him some medication to help with his nausea and discharged him back to the center. Twenty-four hours later, Engholm was back in the ER, struggling to breathe. While in the process of being admitted, he collapsed and died.

State inspectors later cited Genesis for failing to properly examine Engholm during his previous visit, creating “a life-threatening condition from which (Engholm) died.” According to the inspectors, the nurse practitioner later acknowledged that he should have ordered an abdominal X-ray, if only to rule out a possible bowel obstruction. But Craig Cooper, spokesman for the hospital, now says, “We believe the care provided by Genesis to Mr. Engholm was appropriate. We support the medical judgment of our emergency room physicians, who are among the most experienced in the state of Iowa.”

It’s estimated that every two minutes a patient dies in a U.S. hospital because of a medical error, and the vast majority of those errors are never publicly reported. Thanks to the way hospitals report medical errors — or, to be more accurate, the way they fail to report those errors — it’s impossible for consumers to figure out which hospitals are most likely to commit medication errors, surgical errors or diagnostic mistakes.

One organization that is trying to change the culture of secrecy surrounding medical errors is the Heartland Health Research Institute, based in Clive. The organization’s president, David P. Lind, has published a new white paper, “Silently Harmed,” using the best available data, that attempts to quantify medical errors occurring in Iowa hospitals. The numbers are startling:

Lind readily acknowledges his data is extrapolated from national estimates, which assumes Iowa hospitals are no better (or worse) than those in other states. This is part of the problem, he says: Quantifying medical errors is difficult because reporting is voluntary "and not highly practiced.” He argues that without more public disclosure, hospitals can’t be held publicly accountable for their actions, mistakes will continue to be made, and the public will remain in the dark.

Lind is right. It’s telling that while all Iowa hospitals have policies requiring staffers to at least share with one another information on medical errors, even that sort of limited, internal disclosure doesn’t always take place. In 2014, state inspectors reviewed a sampling of medication errors at Dubuque’s Finley Hospital and found numerous instances in which it appeared physicians were never notified when their patients didn’t receive their medication, were given the wrong drug, or were given the wrong dosage.

Patient's head catches fire

Often, the only cases of medical error that come to light are those in which the error is glaringly obvious — as in July 2014, when a patient’s head briefly caught fire during an operation at Iowa Methodist Medical Center in Des Moines.

According to state records, the patient was undergoing surgery to repair a skull fracture when the surgeon wiped the bleeding head wound with gauze pads soaked in alcohol, then grabbed an electronic, pen-shaped device that uses heat to cauterize a wound. The device ignited the alcohol vapor that lingered in the air, setting fire to the gauze and the alcohol on the patient’s head.

The surgeon threw the burning gauze onto the floor where the anesthesiologist tried to stamp out the flames, causing one leg of his pants to catch fire. A nurse standing behind the surgeon saw flames on the patient’s head and quickly extinguished them. Others threw water and towels on the burning gauze and extinguished the fire on the floor. No one was injured, but the hospital was cited for the error.

Just two weeks earlier, another surgical patient at Methodist sustained burns during a heart bypass. The surgeon set a cauterizing pen between the patient’s legs for easy access rather than store it in its specially designed holster. An electrical short caused the pen to remain on even when not in use, resulting in burns to the patient’s legs that required additional medical treatment.

No one expects medical professionals to be perfect. But consumers who entrust their health to clinics and hospitals, and are billed thousands of dollars for their services, are entitled to know when mistakes are made.

Under federal regulations, veterans’ hospitals are required to inform patients or their families of “adverse events” that cause patient injury or death. But the vast majority of hospitals in America operate outside that system and are regulated by the states, and only 28 of them have a formalized process that requires hospitals to report adverse events. Iowa is not among them.

To make matters worse, Iowa hospitals — as well as hospital-owned nursing homes — are immune from state fines, thanks to our Legislature. No matter how egregious the violations, state inspectors can't fine an Iowa hospital.

That’s why Covenant Medical Center in Waterloo faced no state fines last winter after a 25-year-old psychiatric patient, Prince Joshua Flomo, froze to death.

Patient's body found after 17 days

According to state records, security camera footage showed Flomo walking out of the hospital, barefoot and clad in nothing but a paper gown, while workers stood by and watched. At the time, there was snow on the ground and a wind chill of 21 degrees below zero.

Inspectors said the video shows Flomo walking down a hallway toward the exit doors and leaving the building “while a physician’s assistant, a registered nurse and a security officer watched him. … The video showed the patient walking, not running at any time, as he left the hospital campus. … The staff did not attempt to intervene or bring the patient back.”

Flomo’s body was found 17 days later, underneath a tarp where he had apparently sought shelter, about 300 feet from the hospital’s entrance.

Covenant, like Genesis Medical Center, was issued a written citation for the patient death. But these citations amount to nothing more than finger-wagging. It’s simply unconscionable that Iowa lawmakers refuse to hold hospitals accountable for errors and outright negligence that results in a patient death.

Unfortunately, it gets worse: Iowa lawmakers have also taken steps to make it harder for patients to pursue justice on their own. Last year, they approved, and the governor signed into law, a measure that allows Iowa hospitals to contact patients with offers to inform patients of medical errors on the condition that those patients not use the information against the hospitals in court.

Apparently, Iowa hospitals can’t be counted on to disclose potential harm to patients simply because it’s the responsible and ethical thing to do. They have demanded the added incentive of minimized legal exposure, and our state lawmakers have happily obliged.

Then there's the matter of regulatory oversight. In Iowa, surgical centers that perform plastic surgery and other procedures can operate with absolutely no state or federal inspections as long as they don't bill Medicare for their services. In fact, the facilities don't even need a state license, which means Iowa regulators don't know how many are out there. Tattoo parlors are more tightly regulated in this state.

None of this will change without action by the Iowa Legislature. Lawmakers need to require licensing and inspection of all surgical centers. They need to bring Iowa into the 21st century and require the reporting of all adverse events that cause serious injury or death. And they need to let state regulators fine hospitals for the same violations that routinely trigger four-figure penalties at Iowa’s independently owned nursing homes.

Every day our legislators delay, six more patients die due to medical errors in Iowa hospitals. The time for action is now.

Patient-care violations at Iowa hospitals

Typically, medical errors in Iowa hospitals are not publicly reported, but here are a few examples of patients who died or were put at risk as a result of regulatory violations during the past three years. No state fines were imposed as a result of any of these violations:

In October 2014, a patient at the University of Iowa Hospitals was allowed outside the psychiatric unit due to what state inspectors called a “breakdown in communication.” The woman ran to a nearby parking garage and threw herself off the fifth floor. She survived the 50-foot fall, but sustained “significant, life-altering injuries,” state inspectors said. In 2007, the hospital paid $200,000 to settle a lawsuit brought by a Minnesota man who attempted suicide by jumping from the fourth floor of a building after being released from treatment at the hospital. Two years later, another psychiatric patient was allowed the leave the hospital unattended, after which he jumped to his death from a hospital parking garage. The hospital apologized to the man’s family and paid a $250,000 settlement. At Trinity Muscatine Hospital last winter, a 70-year-old nursing home resident was participating in a sleep study when she told the staff she wanted to return home. A hospital employee walked the woman to the exit, then retrieved her walker so she could make the three-quarter-mile walk back to the nursing home. At the time, it was just after midnight and there was a wind chill of minus-2 degrees. At about 1 a.m., a passing motorist saw the woman walking near the nursing home, stopped, and escorted the woman into the facility. On Oct. 21, 2014, paramedics were transporting an obese patient with blood in her urine to Great River Medical Center in West Burlington, where the staff — who knew the patient due to several recent admissions — instructed the ambulance to take the patient elsewhere. The ambulance pulled up to the Great River emergency room, and one of the paramedics went inside to talk to an emergency room physician, who again refused to treat the woman, stating — incorrectly — that the hospital didn’t have a bed for someone the patient’s size. The doctor refused to examine the woman and also refused to contact another hospital, saying that was not his responsibility. After 30 minutes, with the patient’s condition deteriorating, the ambulance set out for another hospital 75 miles away, with its lights and siren activated. Great River’s refusal to admit, stabilize or examine the patient caused a “huge delay” in treatment and resulted in a life-threatening condition, state inspectors later said. Over the course of nine days in September 2014, a woman came to the Marshalltown Medical and Surgical Center seven times complaining of debilitating back pain. Tests showed her white blood cell count was four to six times the normal level, which could indicate sepsis, a dangerous and potentially fatal infection. The staff should have done more testing, state inspectors later alleged, but did not. After the woman’s seventh visit to the hospital, she walked out over the protests of the staff. A few days later, the patient’s physician called the hospital to report the woman was dead. One of the medical center’s doctors later told inspectors the patient’s treatment “might have slipped through the cracks.” In August 2013, a 10-year boy arrived in the emergency room at St. Luke’s Hospital in Cedar Rapids with a serious hand injury sustained in a go-cart accident. The on-call orthopedist refused to come to the hospital to examine the child, which resulted in the boy being sent by ambulance to a hospital 130 miles away, where a doctor cleaned and closed the wound, then applied a splint. St. Luke’s was cited for causing a delay of “several hours” during which time the child’s wound remained contaminated by grass and gravel.



For more information

The Iowa Healthcare Collaborative, created through a partnership between the Iowa Hospital Association and the Iowa Medical Society, collects and distributes some data on patient care. The collaborative hosts an online database that allows users to compare a hospital’s numerical score on a few types of adverse events (such as infections and falls) and several procedures (such as emergency room care and heart attack care) against state and national averages. The report can be accessed at http://www.ihconline.org/

The federal government provides consumers with hospital-specific data on patient outcomes at the Hospital Compare web site, https://www.medicare.gov/hospitalcompare By entering their zip code, consumers can look at a profile of hospitals in their area, and see how those hospitals score on specific procedures and treatments.

Conservatively, an estimated 85,000 Iowans — enough to fill both Hilton Coliseum and Kinnick Stadium — are seriously harmed by medical errors each year in Iowa hospitals. That works out to one of every four hospital admissions.

An estimated 2,444 patients are fatally injured each year in Iowa hospitals. That’s one patient death every four hours, which is more than six times the rate at which Iowans are dying in traffic accidents.