U.S.

Hospital Deaths Blamed On Faulty Tests

By CBSNews.com staff CBSNews.com staff

August 1, 2001 / 7:09 PM EDT / CBS

A hospital promised to revamp its laboratory procedures after state investigators confirmed Wednesday that faulty tests led dozens of patients to overdose on a blood-thinning medication. Two of the patients died.

Officials at St. Agnes Medical Center said tests of blood samples from 932 patients were improperly calculated. Some patients received incorrect doses of the anticoagulant warfarin, better known by the brand name Coumadin, between June 4 and July 25, the officials said.

Most patients who received the incorrect test were unharmed, hospital spokeswoman Teresa Heavens said.

The state Health Department said the lab error involved a test which measures blood thickness and is typically used to monitor patients using warfarin.

"People got wrong results and medication was adjusted based on these incorrect results. They were given a higher dosage," said Dr. Bruce Kleger, director of the department's Bureau of Laboratories.

The city medical examiner said two patients, Vincent Arguto, 74, and Louis Vitello, 89, died of intracranial hemorrhage, or bleeding in the brain.

CBS Medical Correspondent Elizabeth Kaledin reports Coumadin is widely prescribed among the elderly because of its ability to prevent blood clotting that can lead to stroke and heart attack. But doctors say it is a difficult drug to manage and patients taking it must have frequent blood tests.

"This test is critical because if the blood is too thin it can predispose you to bleeding, and if it's not thin enough people can have stroke or heart attack," said Dr. Joseph Ouslander of the Wesley Woods Center at Emory University.

In addition, many other medications interfere with Coumadin's effect. St. Agnes Medical Center was using a new more sensitive blood test, but apparently not everyone knew about it.

"This was clearly a communication problem that happened in the laboratory," said Ouslander.

The state Health Department released its findings Wednesday, confirming the hospital's earlier assessment of the lab's faulty analyses.

St. Agnes voluntarily stopped doing the test soon after the errors were discovered and has been sending the work to an outside lab. Wednesday, the hospital said it is also implementing new lab safeguards and taking steps to ensure the validity of test results.

Experts in the field of medical errors say more often than not, mistakes are caused by faulty systems, not individuals.

"Accidents happen because of a lot of very small kinds of errors or mistakes and all of those come together to make the accident," explained Arthur Levin of the Committee on Quality of Healthcare.

In the last two years, two major studies have been done in an attempt to calculate the number of people killed as a result of medical errors. The hope is exposing the problem will help hospitals and doctors learn from their mistakes. Two years later one has to wonder what's been learned.