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(Times Union (Albany, NY) Via Acquire Media NewsEdge) CORRECTION: Read the entire Dead by Mistake special report, with additional stories, photos, videos, maps and database of hospital errors, at Aug. 9--Read the entire Dead by Mistake special report, with additional stories, photos, videos, maps and database of hospital errors, at http://www.deadbymistake.com.

Stopping only to check the caller ID every few seconds on his incessantly ringing cellphone, Dr. Randy Panther types in an order at the nurses' station for an antibiotic to treat a patient's infection.

A pop-up window on the screen warns that the patient has a drug allergy. The computer suggests a more appropriate choice.



Down the hall on the same floor at Metropolitan Methodist Hospital in San Antonio, nurse Esther Garcia pushes a medication cart topped with a laptop computer and a hand-held bar code scanner -- the kind used by supermarket checkout clerks on bulky items like 20-pound bags of dog food.

She scans the bar code label on a prepackaged dose of medicine prepared by the pharmacy overnight, then scans the bar code on the patient's hospital bracelet. The laptop informs her she's giving the right patient the right dose.

Both of these systems were designed to fix the two places where medication errors commonly occur in a hospital -- the doctor's prescription pad and the nurse's morning medication rounds. Some research suggests that hospitals using both systems could catch most medication errors.

But few hospitals use them. A survey of 3,049 hospitals published in March found that only 17 percent of U.S. hospitals used the electronic prescription pad, known as computerized provider order entry, or CPOE. Other surveys have found even fewer hospitals use bar coding.

The Institute of Medicine report "To Err is Human" recommended 10 years ago that hospitals take a number of steps that would prevent mistakes in the operating room, in giving patients their medicines -- and in changing the overall culture in hospitals to make safety a priority rather than an afterthought.

Progress has been uneven at best, and expensive investments in electronic medical records, bar coding and CPOE for prescribing medicines have been particularly slow to occur. Although cost is a major factor, experts say hospitals have had other reasons to drag their feet.

The Hospital Corporation of America, the largest private health care system in the country, uses bar coding in all of its 163 hospitals. It has CPOE, the more expensive technology, only in about 20. Metropolitan Methodist is one of those 20. But the CPOE system is still voluntary for physicians -- making it mandatory would require agreement by the medical staff -- and only about 5 percent of the hospital's doctors currently are using it. The rest continue to scribble on paper, putting patients at risk of misread prescriptions.

"I think we're looking at a very steep curve of adoption of CPOE," said Dr. Jonathan Perlin, who became chief medical officer of HCA in 2006 after leading the Veterans Affairs hospital system -- the undisputed leader in such technology.

"When one looks historically at the software technologies that were available, they really weren't built with a professional friendliness," said Perlin, who was named to head a federal advisory committee on health information technology standards.

Disrupting the routine "Most doctors have their routine, the way they practice medicine," said Dr. Ashish Jha, associate professor of health policy at the Harvard School of Public Health, who conducted the hospital survey. "What electronic records do is disrupt that routine. And there's pretty good evidence that for about six months after you implement one of those things, you tend to be less efficient." After doctors become familiar with the systems, however, they become as efficient as before and rarely want to go back, Jha said.

Dr. Kimberly Rask, director of the Emory University Center on Health Outcomes and Quality, said the evidence of CPOE performance hasn't been overwhelming. When Children's Hospital of Pittsburgh launched its CPOE system in 2001, the death rate actually rose for five months. Critics blamed poorly designed software.

"In the last several years, we've seen a literature emerge of medical errors caused by computer systems," said Dr. Robert Wachter, professor of hospital medicine at the University of California at San Francisco. "The systems as they stand now are still fairly clunky and user unfriendly." Although there's been far less research done on the benefits of bar coding, Wachter thinks it might have a significant safety impact in the short run, eliminating many of the high-profile errors that make the news -- such as the overdose of blood thinner that almost killed the newborn twins of actor Dennis Quaid.

The federal stimulus package includes billions to help hospitals and physicians buy health information systems. Without that help, struggling hospitals will be hard-pressed to move forward, said Nancy Foster, vice president for quality and patient safety with the American Hospital Association.

"Over half the hospitals in the country right now are reporting a loss from operations," Foster said. "It means hospitals may be delaying or curtailing some of their investments in new things that might lead to additional safety improvements." Underestimating results Catholic-affiliated Ascension Health is the nation's largest not-for-profit hospital chain, with 67 acute care hospitals in 20 states.

In 2002, three years after "To Err is Human" was published, Ascension officials laid out an ambitious goal to eliminate all preventable deaths in its hospitals. They estimated it would be about 900 a year, or three per day -- roughly 15 percent of deaths involving patients who weren't hospitalized for end-of-life care.

They underestimated. A year after the program began, the system saw a 21 percent drop in overall mortality -- about 1,200 deaths. Not all of them were from errors, but they all were preventable, said Dr. David Pryor, Ascension's chief medical officer.

"We believe that our financial performance has been improved by the work we've done in safety," Pryor said, adding that malpractice costs have declined 35 percent since 2005.

What did they do? They focused on seven quality goals -- preventable deaths, drug errors, falls, pressure ulcers, surgical complications, hospital-acquired infections and newborn safety -- in addition to a collection of safety and quality guidelines contained in national accreditation standards. Programs were developed in a handful of hospitals, tested in others and then implemented widely.

The strategies were intended not to burden staff excessively. And they didn't necessarily include expensive technology such as electronic medical records and CPOE -- although Ascension hospitals gradually are acquiring those systems.

"The way I look at it is to say automation and technology can be very important and helpful," Pryor said. "But if what you do is automate a bad process, you've now got a very expensive bad process." One investment they did make was in simulation training, where medical teams from obstetrics to surgery practice on robotic mannequins -- one of the recommendations in "To Err is Human." The practice sessions are designed to be stressful, with malfunctioning equipment and volunteers pretending to be frantic parents making a sudden entrance.

Afterward, the teams study their mistakes on video -- the way NBA teams do after a game.

The Joint Commission, the national accreditation agency for hospitals, grades them in part on patient safety standards such as nurses reading back verbal orders from doctors, marking the correct surgical site with a pen and special handling of look-alike and sound-alike medications.

That's one reason why Wachter, who has written two books on patient safety, sees an improvement.

"If I were judging patient safety (10 years ago), I would have given us a D-minus. Not an F, because doctors and nurses and hospital administrators didn't want to harm people." Today, he'd give "maybe a B-minus. My sense is we're better than we were." "Some things have improved," said Mary Stefl, dean of health care administration at Trinity University in San Antonio. "Some of the low-hanging fruit has been removed. Now, you have checklists prior to surgery; you mark the spot on which limb you were going to operate on. And afterwards, they count the surgical sponges and instruments so they presumably don't leave anything inside. But it still happens. Somebody assumes someone else did it, or a surgeon refused to go through it and it still happens." Mistakes happen As the sedatives course through the veins of the elderly patient lying on his side at the Audie Murphy Veterans Hospital in San Antonio, nurse Truthann Rivas calls a timeout -- bringing the busy doctor and staff in the procedure room to a halt.

"This is Mr. Everette. He's here for a colonoscopy. Are we all in agreement?" Rivas calls out over the moan and hiss of medical equipment. "Yes," comes the muted response from everyone but the sleeping patient -- a medical liturgy repeated in some form countless times a day throughout the hospital, and in hospitals across the country.

It's the fifth colonoscopy of the morning for Dr. Lawrence Siegel and his team. Each time a new patient is wheeled in, VA rules and Joint Commission standards require a similar timeout to prevent the wrong patient from undergoing the wrong procedure.

"For us it's pretty foolproof, as far as where we're going," said Siegel, a gastrointestinal specialist. "There's only two orifices we go into. The main thing is to be sure the patient is the correct patient." Of course, other things can go wrong. In December, a similar team at the VA hospital in Murfreesboro, Tenn., discovered a problem with an irrigation pump used in colonoscopies. The hospital and the VA's National Center for Patient Safety launched an investigation and found a small but very real risk that fluid flowing back into patients could expose them to infections.

Investigators found the problem extended to at least three VA hospitals. Hospitals throughout the VA system were alerted so they could train staff in the correct procedure. Patients were notified and offered testing for HIV and hepatitis. Congress, as it has in the past when similar VA scandals arose, is holding hearings.

The VA is the largest health care system in the nation with 153 hospitals and 919 clinics scattered across the country. It's been praised by patient safety groups and experts for its efforts to reduce errors. Hospitals use a nonpunitive system for employees to report errors and close calls modeled after NASA's. A team meets within 45 days of a report to identify and fix the cause of that error. Alerts describing the problem and the fix are sent out to all VA hospitals.

It leads the country in the use of electronic medical records, CPOE and bar coding. It pioneered the idea of quickly and honestly disclosing errors to patients.

And still, mistakes happen.

"It's just been a culture thing that if an error happens, it's somebody's fault," said Dr. Jan Patterson, chief of staff at Audie Murphy Veterans Hospital. "We really think that 85 percent of the time it is a system issue. That means that we need to make things foolproof, just like in the aviation industry and the nuclear industry, where there's all these different safeguards and checklists that you go through. We need to make it easier to do the right thing and make it harder to make an error." To see more of the Albany Times Union, or to subscribe to the newspaper, go to http://www.timesunion.com.