Med Gas Mistake Kills Two in New Haven
“All systems failed,” said Alan S. Kliger, MD, chairman of medicine at the
Hospital of St. Raphael in New Haven, Conn., at a news conference held on Jan. 16 where it
was announced that two patients had been killed in the hospital’s cardiac
catheterization lab because of a sequence of human errors and the defective wall outlet
connection of an oxygen flowmeter.
Dr. Charles Riordan,
Vice President of Medical Affairs at the Hospital of St. Raphael, holds up an oxygen
flowmeter at a news conference Wednesday, Jan. 16, 2002, in New Haven, Conn.
“Dot” Herdman, a 72 year old great-grandmother, was undergoing
catheterization on Friday, Jan. 11. The decision was made to give her oxygen. But the
flowmeter was actually plugged into a nitrous oxide outlet. As Herdman’s oxygen
saturation dropped, the staff increased the gas flow because they thought they were
administering oxygen. Instead, the nitrous oxide asphyxiated Herdman. At that time, the
hospital attributed the death to natural causes and no investigation was made.
Sixty-nine year old Joan Cannon entered the cath lab on Tuesday, five days after
Herdman’s death. The staff thought they were giving Cannon oxygen, but her condition
rapidly deteriorated and she died.
Article questions relevance of Joint Commission
Accreditation by the Joint Commission on Accreditation of Healthcare
Organizations (JCAHO) is a poor predictor of the quality of patient outcomes, according to
a study published in the January issue of peer-reviewed quarterly Quality Management in
Health Care.
University of Michigan School of Public Health professors. John R. Griffith and Jeffrey
A. Alexander examined Medicare outcomes by comparing JCAHO scores, submitted by JCAHO,
against Medicare inpatient data prepared annually by consulting firm Solucient (Evanston,
Ill.) for its “The 100 Top Hospitals” benchmark product. Solucient paid the
researchers $10,000 to analyze the “100 Top” criteria, and the article
encourages hospitals to use such benchmarks.
The article says there is no relationship between Medicare-based measures of mortality
and complications and the scores assigned to hospitals by JCAHO. Griffith and Alexander
blame JCAHO criteria, which they call a consensus of what seems to work, rather than
practices tested against real performance.
 Traffic and Road Information
If you thought making that six-hour drive to Syracuse for a
visit with the relatives over the holidays was bad, try it while slithering along the road
shoulder at about three inches per hour! The Web Worm knows that avoiding traffic snaps is
key to any long trip. With that in mind, our weary wanderer sought a trusted source of
traffic and highway reports. And where else would the cyber-segmented one go? To the
Internet, of course.
 The proven clutch-hitter in cross-country trip
planning is the National Traffic and Road Closure Information site from the Department of
Transportation. It collects hyperlinks to traffic reporting sites, construction updates
and suggested routes classified by each of the 50 U.S. states. Wanna know how to navigate
Boston’s Big Dig? How to avoid jams on “The Five” in LA? Wanna learn how to
bypass the tightening of Washington’s Beltway? This is the source.
The site isn’t fancy and doesn’t offer flashy
graphics, but its links to traffic cameras proved invaluable as our highway-huffing friend
embarked on a nationwide tour to publicize his new book, “Men are from Mars, Worms
are from Dirt.” |
National
Traffic and Road Information
http://www.fhwa.dot.gov/trafficinfo/index.htm
|
|
Among the complaints heard from patients in assisted living
facilities, many concern the quality of the food. After years of home-cooked hearty meals,
elderly patients have difficulty adjusting to the bland, mass-prepared, “dietarily
correct” meals shovelled out each day.
 Recently, the 60-facility AURUM Network, based in Gloucester, Mass., addressed
that problem. It teamed up with some of New England’s top chefs to create menus of
delectable victuals for its residents, train its institutional personnel to prepare these
treats, and the company is recruiting high-quality chefs from area restaurants for its
dining rooms so they can create new top-notch meals for residents.
AURUM even forged a unique alliance with one of
Boston’s premier eateries, Anthony’s Pier 4, allowing the Network’s chefs
to learn the secrets behind Anthony’s signature lobster bisque and other seafood
treasures. “It makes me feel good knowing that residents of these facilities will be
able to enjoy Anthony’s Pier 4 food,” said restaurant owner Anthony Athanas.
The meals have been so well received that AURUM and
Anthony’s joined to publish a cookbook. (Sample recipes can be found at www.aurumnetwork.com. ) While a tasty meal does not
solve all of the difficulties faced when a loved one enters an assisted living facility,
it’s heartening to know quality improvement, benchmarking and best-practices have
found their way into the kitchen. |
No. Carolina 2001
The North Carolina Biomedical Association held its annual symposium at Pinehurst this
year, with over 200 attendees enjoying good food, fun and a great education over the event’s
three days.
Below, Joseph (Joey) M. Cahoon, CBET, Assistant Manager of the Biomedical Department at
University Health Systems of Eastern Carolina/Pitt County Memorial Hospital, listens at
the awards luncheon moments before he was named Hill Rom Professional of the Year.
Toba Managing Morse Medical
Tosha Toba joined Seattle-based independent service provider Morse Medical in
January and she will oversee the company’s day-to-day operations as General Manager.
Prior to Morse Medical, Toba was with the multivendor program of Philips Medical
Systems, and had managed clinical engineering programs at VA Puget Sound Health Care
System and the Providence campus of Swedish Medical Center.
Philips buys Richardson’s tube unit
Philips Medical Systems International B.V. and Richardson Electronics Ltd.
(LaFox, Ill.) announced on Jan. 16 that they signed a letter of intent for Philips to
purchase Richardson’s business for the reloading and distribution of X-ray, CT and
image intensifier tubes.
Medical glassware is currently within Richardson’s Medical Systems Group, which
posted sales of $40 million in the fiscal year that ended May 31, 2001. Medical glassware
accounted for approximately half of those revenues.
GE Medical Makes More Money
GE Medical Systems increased revenues by 16 percent and operating profit by 13
percent in the third quarter of 2001, compared to the third quarter of 2000.
Sales at GE Medical System’s Information Technology unit, which includes patient
monitoring, increased 43 percent over the same quarter in the previous year. On the
diagnostic imaging side, total orders gained 15 percent, with orders for CT systems
advancing 40 percent, open MRI orders climbing 51 percent, and positron emission
tomography (PET) system orders up 127 percent over the third quarter of 2000.
Choice and Baxter Planning systems link up
Choice Logistics, a service parts logistics company based in New York City, announced
on Jan. 14 a strategic alliance with Baxter Planning Systems of Austin, Texas, which
creates Web-based service parts management applications. The two companies will market
integrated services to customers, with Choice providing warehousing, inventory management
and control as well as all logistics services, and Baxter providing inventory planning
software and planning support services.
A typical inventory management project will begin with Choice utilizing its inventory
management system, experience, and in-depth analysis to determine the best locations for
inventory in its network of over 160 Strategic Stocking Locations (SSLs). Once locations
are determined, Baxter’s Prophet application will generate an optimized inventory
plan by part, by location.
Intermountain gives Masterplan nod
In a deal announced in November, Masterplan technology management and maintenance services
became available to member facilities of Intermountain Health Care, a shareholder in group
purchasing organization AmeriNet. The agreement was effective Sept. 15, 2001.
According to a statement issued by AmeriNet, Intermountain facilities will be able to
choose from a variety of Masterplan programs, covering on-site maintenance services
ranging from single modality to comprehensive maintenance programs on diagnostic imaging
and clinical medical devices.
Study says RIS/PACS market on upswing
A new RIS-PACS report from market research firm Frost and Sullivan (San Jose,
Calif.) predicts co-marketing between radiology information systems (RIS) and picture
archiving and communications systems (PACS) will drive future sales in the healthcare
information technology market.
Senior industry analyst and study author Amith Viswanathan calculated the market for
integrated RIS/PACS products generated revenues of $150.6 million in 2001, adding that it
“will attain a market size somewhere between $500 million to $784 million annually in
the year 2004.”
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