Notes 9Patient safety / Sex abuse / Crime in medicine The issues:
Data sources are muzzled.
Exterior enforcement systems lack will and requisite knowledge and
experience.
Interior enforcement systems are inclined to protect rather than manage. * * *
The healthcare economist, Dr. Stuart Altman, has an aphorism: Everyone's first choice is protecting their own turf, but everyone's second choice is doing nothing.
Economist Dr. Stuart Altman's aphorism more specifically says that universal
healthcare coverage that protects one's turf is everyone's first choice — but everyone's second choice is to do nothing.
Dr. Altman is one of the nation's leading experts in healthcare policy and economics. He is a member of The Institute of Medicine of the National Academy of Sciences; a member of the Board of Overseers of the Beth Israel Deaconess Medical Center in Boston, Massachusetts; and, Co Chairman of the Advisory Board
to the Schneider Institute for Health Policy at the Heller Graduate School, Brandeis University. * * *
Accountability: Patient Safety and Policy Reform
(Hastings Center Studies in Ethics.) Edited by Virginia A. Sharpe. 276 pp. Washington, D.C., Georgetown University Press, 2004. $49.95. ISBN 1-58901-023-X.
* * *
removed from white wall of silence page
"There is no need to lie. Just don't find out.
If a patient tells you about it, you know they are all liars anyway."
Healthcare professionals simply refuse to accept that one of their own could be incompetent or evil. Speak to patients who became victims. Get their
medical records. See what their doctors recorded when the patients reported what was done to them. Physicians almost never record "patient claims to have been injured by surgeon" or "poisoned by failure to check drug incompatibilities."
Federal mandatory reporting
laws require not only that they record it, but also that they report it. But
they don't. Try it and see. * * * No human being can be trusted to be all-knowing, all-seeing, all-wise. No human being can be trusted always to put your well being above all other considerations. Even parents have to divide their support between children, spouses, their own parents, and the needs of the community.
Even doctors have bad days and bad motivations. That is one reason that crimes against patients are tolerated. The reason the public accepts it is, in part, that patients assume doctors always put the well being of patients above all other considerations.
Kristina A. Fox
The operation was performed on Kristina A. Fox in Portland, Oregon in the fall of 1998. It was supposed to be a routine, minimally invasive laparoscopy to relieve a painful gynecological condition. Stray electric arcs from the instrument burned other parts of her internally leaving her with a malfunctioning bladder and disabling pain that
prevent her from working or bearing children. She's had 13 operations so far to try to survive the injuries. The original problem could have been prevented with a $1000 device that is the equivalent of a ground fault circuit interrupter that detects stray electric arcs from laparoscopic devices. A former operating room nurse, Trudy L.
Hamilton, suffered a similar injury in 1991and has been treated many times since to try to cope with the damage. She said, "I don't think people who say they aren't seeing this problem are lying. I think they are grossly misinformed." How difficult is it for them to become better informed with all the inertia to cover up? This particular
article is mentioned here not because I have the answer to solve it, but because of the view it gives of medicine as a whole. Hospitals are under no obligation to collect such date, and have a huge inclination not to. What that says about them as overseers of patient safety is what must be addressed. The article was
by Barnaby J. Feder in the New York Times on March 17, 2006. At the time of this writing it was accessible at this link.
The Oakland Tribune
Newspapers don't keep their articles on the web forever, but at the time of this writing the link to their article about this is:
http://www.insidebayarea.com/oaklandtribune/ci_3584527 If that no longer works, the link to their homepage is this:
http://www.insidebayarea.com/ What's below is taken from a 03/09/2006 article
about it written by Susan McDonough, a staff writer. A drunk Dr. Frederico Castro-Moure, chief of neurosurgery at Highland Hospital Oakland, was arrested after getting combative in an operating room and later taking a swing at officers, according to the
Alameda County Sheriff's Department. Castro-Moure was arrested just after 8:30 p.m. by sheriff's deputies for being under the influence of alcohol and interfering with the duty of officers, according to a Sheriff's Department report. Deputies believed the doctor was drunk beyond the ability to care for himself and others, Lt. Jim
Knudson said. According to a witness who gave authorities details of the incident, Castro-Moure's angry tirade started when hospital staff questioned his medical authority.
The doctor was on call when Highland received a trauma patient who had fallen two stories and landed on his feet, the witness said. Casto-Moure wanted to operate immediately but was told the instruments would have to be sterilized first. The doctor then threw a "huge
fit," according to the witness. He began yelling and swearing at staff, telling them "he didn't (expletive) care what hospital procedure was." The charge nurse refused to admit the patient into the operating room until the instruments were re-sterilized, the witness said. The doctor began intimidating the charge nurse by punching his fist
into his hand while walking toward her, according to the witness. When it appeared the doctor would follow her into a private locker room, someone on staff alerted sheriff's deputies at the hospital to the situation. When deputies arrived at the operating room, Castro-Moure came around the corner.
"What the (expletive) do you want?" he screamed at the deputies, one witness reported. "Do you know that I am a (expletive) doctor, and I'm going to do what I want," he said, according to the witness.
The officers tried to calm the doctor, but Castro-Moure resisted, deputies reported. He shoved one officer and took a swing at another. Deputies said they had to wrestle the doctor to the ground to handcuff him.
BMJ (British Medical Journal) 2000;320:759-763 ( 18 March )Clinical reviewReporting and preventing medical
mishaps: lessons from non-medical near miss reporting systemsby Paul Barach, clinical fellow, Stephen D Small, assistant anaesthetist.
Department of Anesthesia and Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA Reducing mishaps from medical management is central to efforts to improve quality and lower costs in
healthcare. 195,000
patients die unnecessarily each year in medicine. When they estimated that it
was only 100 000 patients, those along with the many more who were injured
unnecessarily, it was estimated that the annual cost of that was $9 billion. Underreporting of adverse events is estimated to range from 50%-96% annually. This annual toll exceeds the combined number of deaths and injuries from motor and air crashes, suicides, falls, poisonings, and drownings. Many stakeholders in
healthcare have
begun to work together to resolve the moral, scientific, legal, and practical dilemmas of medical mishaps. To achieve this goal, an environment fostering a rich reporting culture must be created to capture accurate and detailed data about nuances of care. At
the time of this writing, the full article could be seen at the BMJ web site at this link:
http://bmj.bmjjournals.com/cgi/content/full/320/7237/759?view=full&pmid=10720361
The police have a policy
When I took a case to the police, they repeated over and over that they have a policy of never duplicating the investigation of another agency like a state medical board. I questioned it, but they kept repeating it. "That's just our policy." If I call the police without presenting a case and ask about that policy, I'm told that they would
have a hard time dealing in hypotheticals. I am trying to determine if it is a written policy or one of those things that some departments assume. I am working to get access to a police department's Policy and Procedure Manual as a beginning of that investigation. Whether or not it is written, and whether or not the
police will confirm that it is a policy, I personally have been told by more than one police officer that they would not duplicate investigation that the state medical board had accepted. But, of course, the police also insisted that if it happened in a hospital, then it was civil and not criminal. The amount of nonsense that police
will repeat and argue in order to thwart a complaint being brought by a victim of a crime in medicine is perplexing. Patients who are victims need help, not perplexities. We need a phone number for them to call. Return to Kashyap
Pauker
According to Stephen G. Pauker, M.D. in the New England Journal of Medicine, Volume 355:218-219 July 13, 2006 Number 2, the core problem in hospitals is the inability of the system and its managers to solicit and integrate the knowledge and experience of front-line workers (physicians, nurses, and support staff). Any way you look at it,
healthcare workers won't report. Even federal mandatory reporting laws have had no effect on this. Stephen G. Pauker, M.D.
Tufts–New England Medical Center
Boston, MA 02111
spauker@tufts-nemc.org Hit your back button to return to where you were
or try this link Quotes
Quotes from Arthur Levin and Charles B. Inlander are from an article in the New York Times, July 21, 2006 called "Report Finds a Heavy Toll From Medication Errors" by Gardiner Harris. Even though, according to the report, most drug errors do not lead to injury, they are so widespread that hospital patients should
expect to suffer one every day that they remain hospitalized.
Novel:
MARKER, by Robin Cook. (Berkley, $9.99.) A pair of New York City medical
examiners investigate a series of hospital deaths following routine surgery. Jaz,
the individual responsible for all of the unexplained deaths is a frustrated
nurse psychopath. She is obsessesed with physical fitness and dedicated to
maintaining her edge of physical strength. "Jaz" is paranoid to the extant and
has been contacted by two mysterious and unknown individuals to do "contract"
terminations of select patients in the hospital where she is employed. She is
highly successful with her terminations and is building her savings to advance
her lifestyle.
Liabilities, errors:
seven years (on average) of legal tangling, risk of financial ruin as well as
possibly losing the ability to continue practicing medicine Among the precedents for complaining about specific companies and people online is:
http://badbusinessbureau.com/
According the the Australian government 11% of all deaths in Australia result
from medical errors. A British journal said that 10% of all patients in
the hospital are harmed.
October 31, 2006
some hospital administrators and experts in human factors argue that aviation
safety principles are not wholly transferable to health care. “Medicine is a
more complex environment with more professionals interacting than in aviation,”
said Robert Helmreich, professor of psychology at the University of Texas at
Austin and director of its Human Factors Research Project, which studies team
performance and the influence of culture and behavior in aviation and health
care.
The definition of an error in health care, Professor Helmreich said, is
“fuzzier” than in aviation, where it is easier to identify a “foul-up” and who
was responsible. Health care providers’ fear of litigation and losing their
medical licenses also hinders the honest reporting of mistakes, whereas aviators
are often inoculated against punishment if they promptly report incidents to the
authorities. Training programs developed by pilots without knowledge of health
care realities can be “appallingly bad,” he said.
More successful are programs developed by consulting firms like LifeWings in
Memphis and the Surgical Safety Institute in Tampa, Fla., both of which have
professional pilots and physicians developing their training materials and
serving on their advisory boards.
Some institutions, like Johns Hopkins, have created their own in-house training
programs and safety structures based on aviation. “Aviation provided us with the
ideas, which we then modified for health care as well as our particular
situation,” said Dr. Peter Pronovost, the director of the Center of Innovation
in Quality Patient Care at Johns Hopkins.
* *
*
"I also have learned with great pain that the vilification of patients who
sue continues after trial. Because we sued, healthcare providers in our
hometown refused to treat us in a manner that I was surprised to learn was
legal. There is one pediatric neurologist in the state of Idaho, and he
informed us by registered letter that he would not treat Cal even in the
event of an emergency. When Pat experienced a leakage in spinal fluid while
recovering from spinal surgery, we were informed that the hospital where Cal
had been injured would not admit him. We were forced to airlift Pat out of
state at a cost of $13,000. He needed six stitches, which a resident
performed."
July / August 2007
Patient Safety and Quality Healthcare newsletter
We're Not Your Enemy
An Appeal from a Consumer to Re-imagine Tort Reform
By Susan S. Sheridan, MIM, MBA, and Martin J. Hatlie, JD
http://www.psqh.com/julaug07/tortreform.html
Just try to find anyone in healthcare who is aware that they are part of a
system that works this way.
Hit your back button to return to where you were
from A Basic Hospital To-Do List Saves Lives
by Jane E. Brody
The New York Times, Tuesday, January 22, 2008, page D7
When inserting a central venous catheter, doctors should do the following:
1. Wash their hands with soap.
2. Clean the patient's skin with chlorhexidine antiseptic.
3. Put sterile drapes over the entire patient.
4. Wear a sterile mask, hat, gown and gloves.
5. Put a sterile dressing of the catheter site.
. . . in the crush of crisis medicine, one or more of these steps is often
neglected . . . What made the program work in Michigan was continuous - and
anonymous - collection of data.
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There needs to be something analogous to the Consumer Product Safety
Commission that looks at the world from the patient's perspective, with the
mandate to look at abuses, collect data about them and recommend changes.
The organizations springing up to try to
help patients have no official status and no authority and usually little
expertise to be of use to injured patients. At Links
for Injured Patients I give a rundown on some of them, like the review about
the Josie King Foundation that shows why so
little progress is made even in the face of impressive efforts. There needs to be an official
institution with injured patients on the board who understand what the world is
like for injured patients. In Great Britain they have figured that out (see
Reform).
Healthcare professionals cannot represent the interests of
patients. They believe each other and they don't believe patients. It is a
circle that reinforces their own self-serving view of the world and leaves them complacent about
hundreds of thousands of unnecessary deaths per year - an acceptable cost to
them.
One of the themes of this site is why this will continue to
be the case as long as doctors and
nurses are in charge of patient safety. If I rewrite
it three times a year for the next ten
years, maybe I'll find a way to make my point in less than forty thousand words,
but even then I doubt it can be done without offending people in medicine, which
partly is why it is so difficult to communicate about this. There is a
virtual agreement not to ask the big questions or look at the fundamental
problems so as not to offend anyone in the medical community. Everywhere in
patient safety people are polishing varnish as though the wood is not rotten.
Facts and cases have made no impression on current assumptions. I am searching
for how to speak in the face of that. One of my attempts is through fiction - muckraking, I guess
- like this chapter in progress.
In the meantime, the medical community enjoys perverse
incentives and comfortable blindness. The people who are suffering not only are
not in charge but are not even heard for the most part. Autopsies
and honest tracking of the long term results of care would be two ways for
medicine to
start listening.
Instead, wisdom comes from the collective agreement of people who get paid no
matter what the outcome for patients. That doesn't work in any field.
Hit your back button to return to where you were
3% get lawyers
Harvard researcher Dr. David Studdert in
a 1999 study of 14,700 medical charts found that of the patients who
suffered negligent injury, 97% did not sue.
However, Studdert studied only the legitimate grievances of
which there was a written record. According to Wald and Shojania (see below)
only 1.5% of all adverse events result in a report. What Studdert really is
saying is that of the small percentage of injured patients whose legitimate
grievances get reported in medical charts, 3% get legal representation. So the
decimal point needs to be moved to the left to describe the percentage of
injured patients who get legal representation - .3% or .03%. Hit your back button to return to where you were
1.5% report rate of adverse events
This fact is cited in:
Making Health Care Safer
A Critical Analysis of Patient Safety Practices
Prepared for: Agency for Healthcare Research and Quality, Contract No.
290-97-0013
Prepared by: University of California at San Francisco (UCSF)-Stanford
University Evidence-based Practice Center
The full report is available on line at:
http://www.ahrq.gov/clinic/ptsafety/chap4.htm
Chapter 4. Incident Reporting
Heidi Wald, M.D., University of Pennsylvania School of Medicine
Kaveh G. Shojania, M.D., University of California, San Francisco School of
Medicine
"Most hospitals' incident reporting systems fail to capture the majority of
errors and near misses. Studies of medical services suggest that only 1.5% of
all adverse events result in an incident report and only 6% of adverse drug
events are identified through traditional incident reporting or a telephone
hotline. The American College of Surgeons estimates that incident reports
generally capture only 5-30% of adverse events. A study of a general surgery
service showed that only 20% of complications on a surgical service ever
resulted in discussion at Morbidity and Mortality rounds."
See also:
"Disclosing unanticipated outcome to patients: The art and
practice"
by Thomas Gallagher, Lucian Leape and others
Journal of Patient Safety, September 2007
". . . available evidence suggests that open communication of unanticipated
outcomes occurs infrequently."
See also:
The Silence
by Michael L. Millenson
in Health Affairs, 22, no. 2 (2003): 103-112
http://content.healthaffairs.org/cgi/content/abstract/22/2/103
He says that there
remains within healthcare a refusal to confront providers’ responsibility for
the problems. He suggests initiating emergency
corrective-action comparable to Flexner’s crusade against charlatan medical
schools.
For a personal story about it, see also:
The aftermath of a 'never event'
A child's unexplained death and a system seemingly designed to thwart justice
By: Dale Ann Micalizzi
Modern Healthcare March 3, 2008
"The immediate silence from the physicians, nurses and the hospital's chief
executive officer was deafening. I felt connected with the staff, having worked
for an HMO in the area for a number of years. Now, all I was seeing was a
classic pattern of denial and defense."
In the same breath that healthcare professionals insist that they and their
colleagues report everything, they say that "of course you have to protect
yourself from lawsuits" - which is done by not reporting anything.
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More from her same article above:
Dale Ann Micalizzi of Justin's Hope
http://www.taskforce.org/justinhope.asp
"I never wanted lawyers involved. I never wanted to question a physician's
judgment or a hospital's care. There was no other option available to us. . . "
". . . it isn't worth a lawyer's time to accept such a case unless the
evidence is overwhelming and an easy settlement attainable.
"A federal judge in Washington, who is a family member, recommended that we
educate ourselves on how such cases work. Traveling several hours west, my
husband and I met with a law professor and attended classes at a law school to
learn the rules of the game."
Hit your back button to return to where you were
* *
*
Patients are five times more likely to die from visiting
hospitals than from not having health insurance, according to the not-for-profit
Committee to Reduce Infection Deaths. And yet to hear the presidential
candidates talk about it, insurance is the problem. The patients who are dying
do not have a place to complain about problems or a voice to influence
legislation or even a way to make known to candidates what the issues are in
healthcare. We need a way. We need a voice. We need a professional institution
representing and protecting and helping patients.
Medicine is a sick patient whose reasoning and judgment often are
untrustworthy. It is apt to slide back into the same old destructive habits
without some firm and concrete correctives in place.
One patient, who called after seeing this site, had spoken to a coroner who
said he would never go to "that" hospital. Why can't patients know what he
knows?
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