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* The accidental nature of former Sun-Times Chairman James Tyree’s death was not exactly played up in the media coverage. But the medical mistake was apparently serious enough to result in a threat from the federal government…
A threat by federal officials to end the University of Chicago Medical Center’s participation in Medicare after the death of Sun-Times Media Holdings Chairman James Tyree was dropped Thursday after a follow-up investigation found that problems identified at the hospital had been resolved.
In a public notice issued this week, the federal Centers for Medicare and Medicaid Services (CMS) warned the hospital it would no longer make Medicare payments for inpatient services after April 28 because an investigation found “deficiencies . . . so serious they constitute an immediate threat to patient health and safety.”
The notice did not specify what prompted the investigation by the Illinois Department of Public Health and the Joint Commission, but sources said it was Tyree’s March 16 death at the hospital of an air embolism during removal of a dialysis catheter.
The investigation “pointed to the issue of training of individuals performing these [catheter] procedures,” CMS spokeswoman Elizabeth Surgener said. “When we looked into that, we found a lack of documentation of training in accordance with hospital policy.”
* Tyree died after an air bubble got into his bloodstream when a dialysis catheter was removed. This sort of mistake is classified as a “never event” by Medicare. But the hospital has apparently addressed the problem…
The U. of C. said it received a notice today that the medical center’s “participation in the Medicare program remains intact” after submitting a “thorough plan of correction to demonstrate continued and sustained compliance with the Medicare conditions of participation.”
Most health facilities that face the loss of Medicare funding eventually address government inquiries before funding is stripped.
Nevertheless, the government’s move shows the increasing seriousness those who pay for health care place on the quality of medical care. The error at the U. of C. that contributed to Tyree’s death falls into a category known as a “never event,” which means it is a preventable situation. […]
“Documentation, which was at the center of the investigation, has been improved and centralized,” the medical center said in today’s statement. “The investigations confirmed that all related personnel have appropriate training, experience, competency and credentialing.”
Thoughts on this?
posted by Rich Miller
Friday, Apr 15, 11 @ 10:47 am
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“Accidental nature”, “medical mistake”?
Clearly it wasn’t intentional, but lets not obscure the fact that this was a clear case of negligence and medical malpractice.
The feds were right to investigate, but I think that as long as the problem really was a lack of documentation of their training and the actual training took place, I think leaving their medicare and medicaid eligibility intact was the right call.
However, the state should look at the long list of procedures currently performed by Certified Nursing Assistants that used to be performed by registered nurses and consider going back to the old way of doing things.
Comment by Yellow Dog Democrat Friday, Apr 15, 11 @ 11:23 am
Geez, when a rich guy can die from mistakes at University of Chicago Medical Center…. stay healthy.
One thing that springs to mind: it’s good to see the federales aren’t afraid to get tough with a hospital group that has some very high friends in the very highest places.
Comment by wordslinger Friday, Apr 15, 11 @ 11:41 am
About 18 years ago, a U of C dialysis center accidentally killed a couple of patients and that made the papers. If memory serves, the fluid in the machine had become contaminated. I don’t recall what fallout took place afterwards, but the deaths popped back into my mind when the cause of Tyree’s death was reported.
Comment by Boone Logan Square Friday, Apr 15, 11 @ 12:38 pm
Never go into a hospital if you can avoid it. 100,000 people a year die from hospital-acquired infections alone, in addition to the common tragedies such as Mr. Tyree from “never events”–events that are so predictable and preventable that they’re “never” supposed to happen.
Hospitals and health care systems are still run too often as loose doctor fiefdoms without the type of top-down systematic , uniform and precise processes and procedures you’d find in other industries, based on data and rigorous managerial oversight.
Comment by Chicago Dem Friday, Apr 15, 11 @ 12:55 pm
I would be curious to know if the procedure was being performed by some type of technician or aid or non-rn level nurse.
As a soicety we are pushing the forced reduction of health care costs, which in turns man more of our medical care is provided by lower paid positions these kind o accidents will increase.
We wont demnad that movie stars and atheltes be limited to making small amounts of money, but we dont want to pay for RN’s and doctors to provide our health care.
Comment by Ghost Friday, Apr 15, 11 @ 1:17 pm
One event does not bring a complete investigation. Things happen over time and a pattern gets documented which internal QA procedures should pick up. Investigations pop in when things do not go well over time. Having a well known person involved just picks up the pace.
Comment by zatoichi Friday, Apr 15, 11 @ 1:36 pm
and, U. of C. is not a level 1 trauma center…incredible. while many of their departments rank highly nationally, the lack of level 1 trauma and the mistake at hand makes one very antsy if one is on the South Side and in need of urgent care. scary.
Comment by amalia Friday, Apr 15, 11 @ 4:36 pm
The catheter removal was performed by a physician’s assistant. Heads are rolling over there now… UCMC didn’t have a ton of financial support to begin with (in comparison to Northwestern Memorial, anyway). I imagine many former donors are distancing themselves now.
Comment by Bex Monday, Apr 18, 11 @ 9:23 am