This is an archived article that was published on sltrib.com in 2008, and information in the article may be outdated. It is provided only for personal research purposes and may not be reprinted.
Last December, a man entered Uintah Basin Medical Center's emergency room feeling weak, tired and out of breath. He was severely anemic and needed a blood transfusion.
Staff started a unit of A+ blood at noon. Seven hours later the man, whose blood type was O+, was dead. He had been given blood meant for another patient with a similar sounding name.
The hospital blamed complacency: Staff didn't match the blood's label with the patient's name at the hospital blood bank or when they brought it to his room, according to a state health department review.
Tragedies like that are never supposed to happen. But these so-called "never events," the most serious medical errors, occurred - at least - an average of once every six days in Utah hospitals and surgical centers, with 57 reported last year.
And what happened to the patients? Twenty-seven died and 28 were severely injured, losing physical or mental function, according to health department data requested by The Salt Lake Tribune. Another patient disappeared, and one case involved nonconsensual sexual contact in a hospital.
The errors include a 10-day-old baby who suffered a skull fracture after staff dropped her and a patient with a severe bed sore that spread deep beneath the skin.
Deadly errors. Utah started tracking never events, also called sentinel events, in 2001, after a landmark study by the Institute of Medicine titled "To Err is Human: Building a Safer Health System." The IOM estimates medical errors may cause 98,000 deaths a year.
The number of serious errors - which are reported voluntarily by Utah facilities - has continued to increase, partly because the state last year increased the number of errors that qualify. There are about 272,000 hospital discharges a year in Utah.
Still, Iona Thraen, director of patient safety for the health department, said federal estimates indicate hundreds more happen - for an estimated 350 deaths a year in Utah.
"The whole experience of medicine is risky," she said, adding doctors and nurses are "as distraught about the experience as the patients and families who experienced it."
Utah tracks 32 types of these serious errors, which it defines as unanticipated deaths or major permanent loss of function, not related to the patients' illness or condition. Examples include surgeries performed on the wrong patient or body part, medication errors and any criminal event.
The annual report on these errors does not identify the facilities, although the names are sometimes included in other documents. The state says its goal is not to penalize hospitals, but ferret out systemwide problems and find fixes.
Scott Williams, chief medical officer for the six Mountain Star-owned hospitals in Utah, including St. Mark's in Salt Lake County, developed the reporting system when he previously worked for the state.
"The citizens should be reassured there's a system in place to monitor this," Williams said. "You have a 99 percent chance of going into hospitals and coming out without having had a serious mistake being made."
Wrong surgery, wrong drug. Still, the numbers are sobering. Surgical errors continue, despite a 2005 statewide campaign to standardize the way surgeries are performed in operating rooms. One explanation could be that hospitals are now reporting errors throughout facilities, such as emergency rooms, Thraen said.
Last year, nine Utah surgeries were either done on the wrong site, or the wrong surgery was performed. In seven surgeries, foreign objects were accidentally left inside a patient. In one case, surgeons discovered a hemostat, which resembles scissors, from a surgery years earlier.
Six patients had serious injuries from falls. Five full-term newborns died. Five patients committed suicide either at the facility or within six days of being discharged. One medical staff member criminally withheld medicine from a patient.
The data shows most errors happen to men and occur in operating rooms.
The problem is often lack of communication among hospital staff and lack of close monitoring and assessment of patients, according to the state and the Utah Hospitals and Health Systems Association.
Debra Wynkoop, the association's director of health policy, said hospitals are committed to eliminating preventable errors. "We just don't find it tolerable."
Statewide prevention efforts range from using the same color wrist bands to signify allergies, patients at risk of falling and "do not resuscitate" orders, to developing recommendations on how to lift overweight patients.
Salt Lake City attorney Christian Austin and other medical malpractice lawyers aren't surprised by the figures, and Austin suspects there are many more. But he said hospitals usually settle egregious cases, and patients, who sign confidentiality agreements, aren't allowed to talk.
Vigilance essential. Still, further details of serious errors in Utah hospitals are available to the public in reports of violations of federal health and safety codes.
These reports, which include the names of the hospitals, cover both never events and patient safety problems that don't rise to that level but remain troubling to regulators. Examples include a vulnerable patient disappearing without anyone being notified and a patient being burned in physical therapy.
After the blood mix-up at Duchesne County-owned Uintah Basin Medical Center, the state and Federal Drug Administration investigated and demanded an overhaul of its transfusion policies. The hospital also settled out of court with the family.
Hospital administrator Bradley LeBaron blames a "laissez faire" attitude for the "very unfortunate" event. He noted serial numbers on the blood for the two patients with similar sounding names also shared the first five numbers.
But even after a nurse noticed that numbers on the patient's wristband and the bag didn't match, a lab technician replaced one to match the other. The wrong blood continued to flow.
The error was caught too late. In his last moments of life, the man started moaning, slurring his speech and struggling to breathe.
"It was preventable," LeBaron said. "But if you're not vigilant there's a potential that any one of us at any time can make a mistake."