A patient at 688-bed Columbia Sunrise Hospital and Medical Center in Las Vegas died in April because of a patient-care error, triggering investigations by HCFA, the state of Nevada and the Joint Commission on Accreditation of Healthcare Organizations.
The incident comes to light 10 months after a JCAHO accreditation survey in which hospital workers alleged JCAHO officials didn't address systemic patient-care problems at Columbia Sunrise. The hospital is owned by Columbia/HCA Healthcare Corp. Following the survey, it earned accreditation "with commendation."
The Service Employees International Union, which is trying to organize workers at the hospital, said last week that circumstances surrounding the patient's death show standards of patient care have declined. Hospital executives repeatedly have denied that allegation.
On its own, the SEIU as been investigating the hospital for months as part of its organizing campaign. The SEIU, other unions and consumer groups charge that in their race to reduce costs, many hospitals have cut staffing levels to a point unsafe for patient care. They often cite for-profit healthcare companies such as Columbia as the worst of the lot.
The SEIU also charges that JCAHO accreditation procedures don't take into account deficiencies in staffing, training and supplies (Jan. 27, p. 8).
The Nevada State Health Division confirmed a surgical patient at Columbia Sunrise was transfused with the incorrect type of blood on April 5 and died April 28. A laboratory technician misidentified the patient, the state said.
In its reports, the SEIU had identified the laboratory and specifically, phlebotomy, as weak links in the hospital's quality assurance, due to understaffing and rapid turnover.
Columbia Sunrise spokeswoman Ann Lynch said the incident was "very tragic for us. The policies and procedures of that transfusion process were not followed. We have since strengthened our policies." The hospital changed its wristband policy as a result of the incident, Lynch said.
The Joint Commission confirmed a sentinel event took place at the hospital. A sentinel event has occurred if an error causes a patient death, leading to loss of public confidence in the hospital.
The JCAHO performed a special survey at Sunrise Medical July 9. The findings of the survey were discussed by the JCAHO's accreditation committee at its Sept. 4 meeting, but it deferred action until Oct. 24.
The 14-person accreditation committee could take a number of actions, including placing the hospital on "accreditation watch" pending an analysis of error. Accreditation watch is the designation for an accredited hospital at which the JCAHO has verified a sentinel event.
Separately, the Nevada Bureau of Licensure and Certification undertook a complaint validation survey for HCFA's Region 9 office in San Francisco. The oversight agency for Medicare, HCFA is charged with making sure standards of care are met for federally insured patients.
Hospitals must report any transfusion-related death to the Food and Drug Administration. The FDA forwards the report to a HCFA program that administers a 1988 clinical laboratory improvement law.
In this case, the report concludes that a phlebotomist didn't ask the patient's name and check the armband. "The errors were due to failure to comply with policies the phlebotomists had been aware of prior to the events," the report says.
The report does not specifically cite understaffing in the laboratory. Staffing levels, however, are not a criterion in the regulations the clinical laboratory improvement law must enforce.
Still, the hospital's action plan says it will hire "more extensively trained individuals (when available)." It also is creating the position of phlebotomy supervisor.
SEIU organizer John Canham-Clyne said: "The animating issue in the (organizing) campaign is staffing and work load and patient care. They all come together in the lab. They are severely understaffed. Phlebotomists and other technicians are underpaid. Therefore, there is significant turnover and poor training of these people."
In a report titled "Holding Our Breath," the SEIU wrote that there aren't enough phlebotomists in the hospital to handle routine blood draws and respond to emergency requests.
The SEIU contends the Joint Commission would have better understood the hospital's staffing problems if surveyors had listened to technicians and nurses outside the presence of management (Nov. 4, 1996, p. 14). Low-level workers on patient floors aren't willing to put themselves at risk of retribution if they describe things that might damage accreditation survey results, the SEIU says.
At JCAHO executives' invitation, labor leaders recently visited the agency's Oakbrook Terrace, Ill., headquarters to discuss ways to improve the survey process (Aug. 25, p. 30).
JCAHO President and Chief Executive Officer Dennis O'Leary, M.D., said the JCAHO is thinking about ways to gather input from facility employees.