Do no harm: Some hospitals let a preventable infection kill their patients

When a plane crashes, it’s kind of a big deal. “Continuing coverage now on the Asiana plane crash investigation.” “Investigators try to figure out what went so terribly wrong.” People freak out. There’s usually a big investigation and a bunch of policy changes to make planes safer. A plane crash investigation committee from several nations including the United States are meeting in Tripoli to try and figure out what happened. There’s pretty much a ”zero-tolerance policy” for plane crashes in our society –and luckily planes are very safe because of it. But when a car crashes it’s not really a big deal. No one hears about car crashes on the news. We’ve decided as a society that car crashes are a cost of a really convenient thing. It’s not worth a big investigation or a bunch of news coverage. This video isn’t about cars and planes. It’s about hospitals. Sometimes doctors and nurses, despite their best intentions, hurt patients. A tricky procedure goes wrong, and the patient suffers or dies. This happens all the time in hospitals. One estimate says that at least 210,000 people die every year due to preventable harm in hospitals. That’s a huge number. You know I think we think of hospitals as this place where you go to get better and that’s just what happens, but there’s a lot of risk in, like, going to a hospital, like, there’s, like, a lot of things that go wrong and they don’t necessarily have to. Some hospitals treat medical harm incidents like plane crashes. An unacceptable problem that needs investigation and policy change Other hospitals treat them like car crashes Just a tragic loss of a risky business, but not ultimately preventable. The way hospitals react to harming their patients can have a huge impact on how often these errors occur. And that’s what this video is about–how hospitals react when they harm their patients. So I got interested in medical errors Because it’s this massive problem that we don’t really talk about in health care Sara and I headed to California to visit some people who would help us figure out how and why people are being harmed in hospitals–and whether or not it’s preventable. I quickly realized that we were looking into something that was rarely talked about, but had a huge effect on hospital patients around the country She loved dancing and running and jumping and she never sat down. I mean it’s funny because we had these, like, family… That’s Claire. Her daughter, Nora, was born with an underdeveloped lung, that required her to be in the hospital for quite a bit of time So we were using the beater and I was like, oh, yeah, there’s a song called Beat It so we put it on, and I mean, she used the beater as a microphone, and like I had a spoon and we would Just play it like as loud as possible and she would just sing like “Beat it” During her treatment, Nora contracted something called a central line infection, which I’ll explain in a minute. The day before she got that first line infection, I had a friend over with her daughter and like she was showing Nora how to do push-ups, I mean it was just you know, like totally fine. And then, that was like just that, and then like two days later she got the infection… Our lives, completely, and Nora’s life, completely changed with that first line infection. A central line is a tube that is placed in a vein that goes right to the heart. It’s given to patients who need medicine that’s too acidic to go through a normal IV or to those who need to get their blood drawn often The tube stays there. People walk around with this thing in, and it gives doctors and nurses really quick access to the blood stream. It’s a super useful invention. But we’re talking about putting a tube, through veins that go right to your heart Just as it’s good for giving medicine quickly into your bloodstream, it’s also a foreign object in your most vital organ. So if any bacteria gets in there, it’s a very bad news Nora had four of these central line infections over the course of her life. That’s way above average. Claire thinks that the Stanford hospital, where she was being treated, could have prevented them– and that’s the question we’re trying to answer: Can these infections be prevented? There has to be a better solution! Like this cannot be, because every line infection just… …took it out of her. Every line infection, you know, just took more out of her and more out of her… She’s saying, “Hi, Nora!” Yeah, because I turned it that– you know, I turned it so she could see herself. Doctors and nurses have sanitation protocols when dealing with central lines. But, even so, she contracted three more line infections while she was in the hospital. Her health was rapidly deteriorating as she approached her fourth birthday… And she just like turned to me and was like, “Hold me.” And so I picked her up, and she… like, put her arms and legs around me, and her head kind of went back and she was sort of like gasping to breathe, and then she… She said, “please help me feel better” And she just grabbed me around my neck, like so… …I mean I can still feel it, like it’s so much strength, you know, like just squeezing me, and then she just basically lost consciousness, and just kind of… Nora died. Her arms around her mother’s neck, on November 22nd 2013. Just three weeks before her fourth birthday. There are so many points along the way where like things could have gone differently, you know And there were so many… …unnecessary mistakes that just led to that moment. It’s hard to know whether or not the line infections were the direct cause of her death It’s hard to disentangle everything that was going on with her to give a neat causal story of how she died. But what’s sure is that these line infections caused her and her family immense suffering. Claire thinks that they should have never happened in the first place. She wrote a letter to the Stanford Hospital where Nora died. She basically lined out the mistakes that she saw in the hospital, and offered feedback on patient safety failures. She got this letter in return: “Unfortunately, the placement of center lines is associated with a risk of infection… ” “There is a risk of infection even in the best of circumstances which can never be entirely eliminated… ” “Please be assured, that multiple procedural protocols are in place, to promote hand washing techniques and minimize the chance of infection…” “We understand and recognize your feelings regarding Nora’s care. And we apologize that you were dissatisfied with your experience of LPCH.” So were Nora’s line infections just the result of a risky business, or could they’ve been prevented? Stanford looked at central line infections with the car crash mentality, just an inevitable tragedy, – instead of with a zero tolerance plane crash mentality. But we headed north to a hospital outside of Sacramento, that went seven years in a row without a single central line infection. We wanted to figure out what they were doing to achieve this perfect record I was really interested in this concept of like, should there be any central line infections given what we know… Is zero possible? Like what does it take to get to zero? What are the obstacles there? In 2005 this hospital had 11 central line infections. Research was just starting to come out on how to avoid these central line infections. And this Roseville hospital began to implement it. They had a few powerhouse nurses, that were dedicated to making a difference, and they did. We kind of thought you had infections. Yeah, there was no biggie. It was no big deal it developed over time You know we looked at people we looked at equipment we looked at skill set and Kind of all that came together to really develop the bundle that has been quite effective here. You can’t accept Good enough You know You have to go for eliminating those. If you’ve been at zero and you have an episode you go in and you say you pick it apart and you do a root cause analysis and you say what went wrong? They treated land infections like plane crashes A zero tolerance policy was instituted and they began to see results We got to see these nurses in action as they inserted a central line They suited us up in sterile dressing and began their work. The nurses were meticulous about the procedure They’d instituted standards of sterilization that assured minimum risk of infection Now what I’m going to do is because my hand is not sterile, I touched a tourniquet I’m going to take my first glove out, that I’m going to throw away. Now I’m still sterile. And these weren’t just compassionate nurses who had an intrinsic motivation to do right instead They were operating in a culture where they were expected to do it right. It was a team effort where they had ownership and accountability Where the line infections were unacceptable. When you have an outcome that isn’t what you wanted If you don’t say is there anything we could have done better? Is there any way we could have changed our interventions and resulted in a different outcome? People are gonna get really really sick and they’re gonna die We left the hospital understanding how they had made it to zero central line infections …you just get this very different approach from the two hospitals. One saying: Every error is a mistake, every error can be prevented in this particular type of error. And then one saying this is inevitable, this is the cost of doing business. And… It’s just really striking, two hospitals like three hours away from each other with, very diferent attitudes. As I headed back to DC I kept thinking of Nora If Stanford had an attitude a little bit more like Roseville, maybe she would still be alive today. Just another five year old little girl Surely she and her family wouldn’t have suffered as much To get the final word on this subject. We went to Baltimore to talk to Peter Pronovost at Johns Hopkins Medical Center He’s basically the Godfather of all of the research behind preventing central line infections we started investigating every infection as a defect again a very Important culture change where in the past we just accepted them and we said no no if we really view these as defects Everyone needs to be investigated and reported on and find out why they would happen We routinely invite patients back to inform us to learn with us to share with us It is both healing for them and our clinicians But importantly it also is wise and fruitful for us to learn and improve mistakes We finished up reporting, Sarah and I realized that Nora’s death actually represents two tragedies The first was of course the fact that a little girl suffered and died, but the second and perhaps more harmful tragedy Is that the hospital where it happened didn’t take the opportunity to learn from it. I think that’s worse for patients who are gonna be treated there in the future. It really makes a world of difference in healthcare whether you see patient harm as something that’s preventable or inevitable and Getting people to the preventable mindset from the inevitable one. It has the potential to alleviate a lot of suffering, to prevent a lot of deaths. I became convinced, like attitude towards harm makes all the difference, and That there’s space for our healthcare system to improve to taking a more preventable attitude towards patient harm.

100 thoughts on “Do no harm: Some hospitals let a preventable infection kill their patients

  1. Those car crashes killed me when I saw them, imagine all those lives lost. It may be a person, but the years and all that hard work just to lose it all in a matter of a second. Never getting to say goodbye. We do take it like it’s nothing, but think about this, that person could have changed the world.

  2. Camden Clark in Parkersburg, WV kills people. Doctor Gold, a back surgeon, has disabled two people I know, and killed two more. The standards are too low in my state, he needs to be fired and trialed.

  3. Do you think lots of cation comes for 0 dolar; No. And at Nora's condition, she had a chronicle disease which has higher risk for any infection.

  4. They kill her child then disown the mother says sorry that you feel dissatisfied. This is ridiculous they don't a dang about lives. They only care about money. They need to see that there is more than a number and that there is living breaching lives they are dealing with.

  5. Nah, its just part of the business. They're butchers playing the game of pharma corporations, yall better get that

  6. If healthcare wasn’t privatized the standards would rise bc rich folks wouldn’t want to downgrade. Everyone would get prime medical care.

  7. In november, I was having severe pain in my side for weeks, and i could not keep any food inside of me, and even any water. As i was in the ER, they told me I might have a stomach bug and told me to go home, and wouldn’t give me any meds. A couple weeks later I was in the ER and for the same things because i couldn’t take the pain. My lipase was in the thousands as a teenager, and they immediately gave me morphine and rushed me to a different hospital via ambulance that could better treat me. Sometimes doctors just refuse to listen to their patients. I had bad pancreatitis for weeks but i suffered alone for a long time because I doctor dismissed it as nothing. There are so many issues in hospitals that need to be addressed, thank you for this video.

  8. an M abd M review have found all of these issues and if someone dies as a result hospital treatment in Canada an M and M review is mandatory

  9. I’m sorry, Nora’s story is a very sad one, truly. However, the video is still very lacking in the logistical evidence for the problem it addresses, and instead relies on the story of the single individual. Don’t take me wrong, the hospital treated her in a bad way, but most of the video seems to be based on assumptions and what people “think”. Not that there is anything wrong with that, only that you should complement with statistics of more general cases for better conclusions, you cannot generalize a hospital from one case.

  10. Medical gaslighting -> medical upcoding -> private insurance forward the bill to Medicaid/Medicare -> 33% kickbacks -> no checks and balances with corrupt Dept. Of Health -> Foxes guarding the hen coup -> doctors are conducting anti-human treason

  11. Stanford as in California? The alleged Enterovirus outbreak is rumored to be a Staphylococcus Aureus Pneumonia/Sinus Infection outbreak being covered up .. and worse?

  12. My sister was having an allergic reaction and the hospital told her to take Benadryl and go home. When she went to a different er they gave her different reversal steroids and then epinephrine.

  13. You know.. You could adapt this attitude in all society's illnesses.. Police shooting, corruption, lead poisonings, mass shootings.. I think the US takes all of that stuff with a car accident attitude

  14. Yea, blame it on Stanford Medical and Lucile Packard Children’s, one of the (if not THE) best pediatric hospital in the country.

  15. Biiiiiigg reason why me going to seek medical attention is useless. Doctors simply lie about test results.

  16. steroids ststins antibiotics. believe it or not. many sick and don't know this med is causing death or life change of suffering unexplainable illnes

  17. I shattered my left knee cap and broke my right leg in three places broke a rib and cracked 4 more I also damaged some of my nerves beyond repair, and I was in hospital on and off for 3 years I am now walking again and didn't suffer any issues purely because the hospital said no. No one shall suffer unjustly because we aren't very, very careful all the time.

  18. I have had 5 ports in my chest and my central and picc lines. Every single port became infected and more central lines I can count. Every port have almost killed me. I’ve been through so much medically so I needed them. Thankfully I’ve only had to have one central line in 1.5 years. So many nurses and doctors don’t give it a second thought when it comes to keeping it sterile. I don’t have a spleen so it makes my chances of infection dramatically higher!

  19. This is why the American healthcare system needs changing

    Also, who wants this release this to the greater Internet?

  20. If i was Nora’s mom, I wouldn’t be able to get the image of my daughter dying in my arms. I would then sue the hospital

  21. Unfortunately hospitals aren't in the business of patient care. They're in the business of making money. This was told to me by my doctor.

  22. I get a central line every time I go into the hospital. The hospital treats it almost like surgery — I'm taken into a sterile operating theatre, etc etc. One time it was done in the ER and it was going into my neck, I believe, and I turned to look at what they were doing and they disposed of everything and started over, asking that I not do that for fear that I would breath on (and hence, contaminate) their utensils. Then again, my hospital is one of the top 20 in the entire US. So there you go.

  23. Far too many hospitals all over the world tolerate mistakes as normal things, even when they prove to terminate people's lives.
    Health is the most important thing and we're all in the hands of supposed professionals who should be interested in learning how to constantly improve, because there's no fixing errors of this kind.
    Sadly this is way overlooked unless a certain case gets very famous, there's a publicised pandemic or somebody very famous is affected.
    Governments should take action and impose a zero tolerance policy instead of making people sign agreements, when they have no other choice, to avoid suing.
    It's terrifying to be sick and nowadays we should be able to feel safe in hospitals.
    It's taken for granted that we can get sicker in them, and many people find that it's impossible to claim or get hospitals to admit to mistakes and try to fix them.
    There's nowhere you can go or anything you can do in most cases, and especially without money or resources, and even if you manage to take them to court and win, you might have already lost somebody or been crippled for life, and no amount of money will help that.

  24. Think about all the things that Nora could've expirienced. All the beautiful places she could've visited. All the friends she could've made. Rest is peace, Nora. :''(

  25. This one of the instances, where Tyson deGrasse's comments on the less-48hr shooting fall apart. While averages are good metrics for measuring and illustrating the significance of a figure, but it's worth noting how deadly mass shooting and how there should zero-tolerance in preventing them. Also, that's why NRA is so adamant on excluding gun violence on a CDC recordings.

  26. This is a huge problem in romania, but nobody really cares, since it's the norm here. There is actually a joke about it "you go with one illness, you leave with 5". That happened to me. My little sister was sick, she has a high fever, so my mum took her to the hospital and I came too. They also put me in the hospital, although I just had a common cold. The nurse literally said "i can't let you go home while your sister is here" as a joke. I don't remember well, but i think my sister did get better, but i got so much worse. I was coughing all the time, i couldn't even laugh. And we stayed there just 6 days! It was winter, so the hospitals were full, and they had to send us back home because they didn't have enough space for everyone. I came with a common cold and left having to use inhalers to get rid of the coughing.
    Btw this was in 2014 if I remember correctly. Maybe things got better since then, but i doubt it.

  27. I normally really like Vox’s videos but this wasn’t very good. They didn’t tell me why two hospitals could have such different attitudes, which I think is the most important question for an investigative reporter. This just felt like I was watching an advert of some sort, like I was being sold the idea of the ‘zero tolerance’ approach rather than being told what really caused line infections other than bacteria and mistakes. I don’t see how I’m suppose to believe that one hospital cares and another doesn’t. They said this wasn’t just about compassionate nurses so what’s the big picture?

  28. I totally believe it. Medicine only cares about money it seems. They don’t care to spend money on actually helping people.

  29. i believe God will judge us for everything, for everything! it can’t be that you are a doctor and not care about your patients 😢

  30. They should have also mentioned about superbug, my father got it through central line and past away. He was supposed to be in ICU for only two days, if he was not in the ICU he would have never got that infection.

  31. In most cases the Nurses are better than the doctors. The hospitals are in it for the money and the loss of a life is nothing more than the cost of doing business, sad.

  32. The only problem I have with this video is that y'all handled the subject-matter too lightly in my opinion. From the experience of being a patient in several hospitals plus seeing what family members went through here in New York, I can say that it's worse than what's portrayed in your short documentary.

    Still, for the appreciation that even this amount of information was presented, I say thank you.

  33. This is why I’m terrified of getting a port, which has many similarities to a central line. I have EDS and lots of EDS people have ports to allow for regular infusions. I’ve known too many people that get infections because of lapses in sterile protocols.

  34. I don't think it is really comparable because we do a lot to prevent car crashes but you can't go overboard with it because it is a balancing act when it comes to cars. We could say that the speed limit is 20 kmh everywhere but that isn't reasonable. I'm not saying that there isn't something that could be done that's is reasonable but a controllable environment like a hospital makes more extreme measures reasonable.

  35. A family friend broke her foot and was sent home with an infected leg. After two days she came back and was sent home again. She then send a picture of her leg to a nurse friend who told her to go to another hospital IMMEDIATELY. within two hours she was in surgery because she had a severe case of sepsis that almost killed her. She almost lost her leg because if it too

  36. Yes, I see the point made in this video but there is also a lot of factor in this case that where out of doctors control. Firstly : age, because Nora was so young her immune system was weak/untrained and extra suscebtible to infections +plus kids tend to fidgit with cathethors helping infection speeding into their body.
    Secondly: we don't know the genetics and predespositions of this kid. But there is a clue, heatly kids with no autoimune desiseas etc don't lend themselves in hospitals at age 4. So complications are to be expected.

  37. How will socialized medicine affect hospital accountability? I have doubts that cost reduction won't eventually lead to a quality reduction.

  38. My Granddad died because he was let go by a hospital with infection still in his ear and being a know diabetic, it ended up wrapping around his head and killing him.

  39. Nora would be 10. Think about that you discussing beings who caused the line infections. And “dissatisfied” she lost her daughter. Inhuman people who don’t show any remorse.

  40. I want Vox to do a video about. What happeneds to your unpaid medical bills? Why doesn't it affect your credit score? And why aren't regulators serving up this cake to Congress.

  41. Making the entire team stakeholders in each and every process that goes into placing a central line is Paramount in the process and the conversations the team has amongst each other. This is a simple process and it is why they are so successful.

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