The nurse speaking was from Region's Hospital in St. Paul, where the remains of a stillborn baby were mistaken for laundry and sent to laundry service. The baby was a boy who was stillborn at 22 weeks.

A few days later, Region's officials admitted that a second stillborn baby's remains may have gone to a laundry service as well.

To be sure, mishandling remains is not a direct act of medical negligence. Nor does the fact that a baby was stillborn necessarily imply a medical mistake during the delivery process.

But these two shocking incidents in Minnesota are also a reminder that the child birth process can be fraught with problems for both the mother and the child. For example, if the baby does not get enough oxygen during labor or delivery, the lack of oxygen can cause cerebral palsy.

Pregnancy complications can also occur when a fetus is not positioned to go through the birth canal properly. This type of problem often involves the baby's shoulder. It is a condition called shoulder dystocia (from a Latin word that means distress).

When this happens, it is an obstetrical emergency. But there are procedures that responsive doctors can often take to address it. Some of these are more drastic than others. But the point is that doctors and nurses must remain vigilant to the risk of complications during labor and delivery.

Source: "Hospital laundry worker discovers baby's body in sheets," USA Today, 4-17-13

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And yet, when we become medical patients, healthcare providers often start treating us as if were faceless. We get reduced to medical charts that summarize our medical symptoms or X-rays that seek to show certain parts of the body. This isn't merely dehumanizing. In Minnesota and across the country, it often results in misdiagnosis or other medical errors because one chart or X-ray looks so much like another.

The study's author, Dr. Srini Tridandapani, from Emory University School of Medicine, believes that a photograph should be added to every single medical-imaging study. It would help prevent misidentification errors that lead to misdiagnosis.

The practice of medicine is increasingly collaborative. Primary doctors and nurses must usually collaborate with many others to deliver good medical care. This makes communication with others, such as laboratory technicians, particularly important. Communication with specialists in specific fields of medicine is very important as well.

But in order for communication to be effective, all parties must be clear on which patient is which.

Source: "Adding Patient Photos to X-Rays May Cut Identification Errors," U.S. News & World Report," 4-15-13

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Instead of standing over a patient with a knife, surgeons who perform robotic surgery sit at a computer screen and operate a robotic device. Many of the surgeries performed this way have gone well. But in Minnesota and across the country, there is also concern about surgical errors in freak accidents. These errors put patients at risk of injuries and even death.

The da Vinci device is used for numerous types of surgery. For example, it is often used to perform a hysterectomy, in which a woman's womb is removed. It is also used in gallbladder surgery and in surgery to remove prostates.

And that isn't all. The da Vinci robot is also used in organ transplants, as well as in gastric-bypass and other weight-loss surgery.

In short, the device has had an astonishing impact. But the downside is increasingly becoming known. The Food and Drug Administration is trying to determine why there has been such a spike in reported incidents in which patients have been harmed.

There have already been reports of five patient deaths linked to robotic surgery since the beginning of last year. One of those occurred during a hysterectomy when the surgeon-operated robot cut a blood vessel by accident.

Source: "FDA eyes increase in freak accidents during robotic surgeries," CBS News, 4-9-13

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Those systems enable a doctor to choose the desired medication directly from a computer menu. The prescription is then transmitted directly to the pharmacy to be filled. Though such systems are from perfect, they have the potential to prevent many types of errors.

One of the challenges in doing so is the very pride that dedicated doctors and nurses take in their work. For highly skilled professionals such as these, it can be hard to admit that anyone can make mistakes that harm patients - even someone who truly cares about patients and is well known for paying attention on the job.

For example, a doctor of pharmacy recently wrote an incident in which a veteran nurse mistakenly injected a patient with the wrong medication. The nurse had meant to administer heparin. But she ended up administering insulin instead, after accidently picking up the wrong syringe.

The point is that to prevent medication errors effectively, hospitals and clinics need to be thinking beyond the actions of individuals. They need to design better systems so what similar syringes are not sitting so close to each other at the point of delivery.

Source: "Think You Can't Make Medication Errors?" Outpatient Surgery, Leroy Kromis, March 2013

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A case in point is a new rule intended to improve patient safety by placing limits on the number of hours worked by young doctors who are in training. The purpose of the rule is clear enough: to prevent medical malpractice and improve patient outcomes by making sure medical residents are not overtired. Medical errors by fatigued doctors are a significant problem in Minnesota and across the country.

According to two recent research studies, however, the shorter shift has not really helped patients. In fact, researchers concluded that doctor errors that harm patients increased by 15 to 20 percent compared to residents who worked the longer, more traditional shifts.

It is not clear why errors increased. But one physicians not connected with the research suggested that a failure to adjust intern workload could be involved. If medical residents are expected to do the same amount of work in fewer hours, obviously that is a problem that can potentially put patients at increased risk of harm.

Source: "Studies: Residents make more errors on shorter shifts," USA Today, Janice Lloyd, 3-25-13

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Despite this research, however, medical malpractice in Minnesota and other states continues to occur far too often. As important as new insights are, there is also a need to follow through on implementation of best practices of all types - both old and new.

In the healthcare context, consider, for example, the problem of hand hygiene. For a hundred years, doctors and nurses have known that maintaining proper handwashing protocols is important to protecting patients from hospital-acquired infections.

And yet even today, many medical care providers fail to have programs in place to makes sure that this handwashing really does happen. Research can continue to document the problem. But truly solving the problem requires a common commitment by providers to make it happen.

This month, the well-respected Agency for Healthcare Quality and Research (AHRQ) came out with a new report on ways to better protect patients in hospitals. And improved hand hygiene was there on the list.

Hospitals would do a better job of addressing such problems, many experts believe, if they took a more comprehensive look at patient safety. Dr. Peter Pronovost of John Hopkins, in particular, thinks healthcare administrators should proactively address the need for organizational change to prioritize patient care - and not merely react to this or that aspect of it.

Source: "Hospital Improvement: New Report is a Half-Baked Recipe for Patient Safety," Forbes, Leah Binder, 3-8-13

You'd think, then, that medical practitioners would know how to do it properly. In a recent case in New Orleans, however, a man alleges that cataract removal surgery went terribly wrong. He says he woke up from anesthesia during the surgery - and then had his mouth covered with tape by medical staff after he asked them to stop the operation.

To be sure, this is an extreme case. But anesthesia errors are more common than one might think. According to one study, done in 2008, the national total for patients who wake up during surgery is around 30,000 per year.

What are the consequences of waking up during surgery? The effects on patients range widely. Some have only the briefest of memories of what happened. Others suffer genuine terror, however, along with a high level of pain, and may become temporarily immobilized. After such an experience, it is possible for someone to be plagued with post-traumatic stress disorder.

Of course, giving too strong a dose of anesthesia is potentially a problem too. After all, very strong chemicals are typically involved in administering anesthesia. That is why monitoring of a patient's condition during and after surgery is so important.

Source: "Man Sues Over Loss Of Vision And Alleged Torture After Waking Up During Cataract Surgery," Opposing Views, Sarah Rae Fruchtnicht, 2-26-13

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