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What a New Doctor Learned About Medical Mistakes From Her Mom’s Death

Dr. Elaine Goodman says hospital culture has to embrace the notion that reporting and tracking medical errors are a positive, not punitive, step: “It’s not enough just to have caring, qualified people to keep the patient safe.”

Dr. Elaine Goodman (Photo: Ryan T. Conaty)

For Dr. Elaine Goodman, the strongest lessons in patient safety didn’t come from her training. They came from her mother’s death. 

Goodman had just finished her first year of medical school when she found herself spending months at the bedside of her 63-year-old mom, who was battling breast cancer in the hospital.

One morning she arrived to find her mother’s face and hands bloodied. Hallucinating and disoriented, her mom had yanked the cranial staples inserted during a recent procedure from her head.

Another time, a stethoscope fell on her mom’s face and gave her a black eye. She suffered frequent falls and preventable side effects from drugs. And she narrowly missed having an unnecessary brain operation and getting an incorrect drug.

“It was really eye opening for me to see the reality of how difficult it was to keep her safe in the hospital,” Goodman said. “It’s not enough just to have caring, qualified people to keep the patient safe.”

Goodman believes the incidents hastened the decline of her mother, who died in 2008 after six months in the hospital. A Harvard Medical School grad, Goodman is now a second-year resident in internal medicine and primary care at Brigham and Women’s Hospital in Boston.

Goodman shared her story after completing our Provider Questionnaire, part of our ongoing reporting on patient safety. ProPublica confirmed details of her mother’s story with one of the physicians who treated her and by reviewing her records. This interview with Goodman has been edited for clarity and length.

 

What did your experience with your mom teach you about medicine?

The hospital she was in is a nationally ranked hospital near Seattle. It wasn’t that we felt the place was not up to snuff or not capable of providing good care. But I hadn’t realized how hard it is to keep a complicated patient safe in the hospital. The harm is rarely caused by actual negligence. The vast majority of cases involve a lot of people doing fairly reasonable things, and somehow something just falls through the cracks.

One day my mom fell out of bed in middle of the night. They had bed alarms to notify nurse if a patient starts to fall out of bed. But there’s also a chair alarm, and the nurses showed us that there were only enough electric outlets for one alarm at a time, and the alarms had identical cords – making it hard for the nurses to tell which alarm was plugged in. The day my mom fell, the wrong alarm was plugged in.

There are lots of easy solutions to this. They could make the cords different. Or they could have two outlets, so both could be plugged in. I certainly hadn’t thought about that as a medical student, but all of a sudden it became the most important thing in my day when my mom was in the hospital.

Medication errors were frequent. My mom was on a seizure medication that needed the dose adjusted according to her nutritional status. The physicians probably knew this, but with all the handoffs, a new doctor would come in, see the drug level was low in her blood – and without carefully observing her nutrition – and then up the dose. She was being accidentally overdosed on the medication which caused her to sleep for days. As somebody who has a life expectancy on the order of months, those days were very important to us.

The biggest error related to her chemotherapy, which was administered by a device straight into the fluid of her brain. They’d give her the chemo about once a week, and it was supposed to last an entire week. One weekend her normal oncologist wasn’t on so the covering physician administered the chemo. About a week later her normal oncologist came to us in tears. She’d discovered that her colleague had not administered the right chemotherapy drug, and the type she’d received had only lasted a day, not a week. My mom had effectively gone for a week without getting any treatment. For her this probably didn’t change her life expectancy drastically, but it probably changed it a little bit. But this event itself was really terrifying. It had the potential to make a huge difference in the life expectancy of other patients.

 

How did the hospital doctors and officials respond?

We [family] had a lot of conversations with the hospital administrators about what they were going to do about such a big medication error. We arranged to become members of the hospital’s patient safety committee. That got us involved in a way that made us feel they were addressing it.

On the committee I watched how the hospital addressed the error. It turned out the drug that had been incorrectly administered had a name that was almost identical to the name of the correct drug, and the labels were almost identical. Plus, the hospital did not have a pharmacist who had specific expertise in chemotherapeutics. It was a case that illustrated what they call the “Swiss cheese model” for how errors occur. All the holes just line up and then the mistake is made. There were no good systems in place to make sure that if somebody didn’t catch it, there was some hard stop to keep this from happening.

The hospital ended up hiring a new chemotherapy pharmacist, training the nurses and changing how the chemotherapy drugs were ordered and labeled.

 

What do you see as the causes of ongoing patient safety problems?

Complexity. There are exponentially more treatments, medications and technologies now compared to a few decades ago. We also have so many different ways patients are insured, different facilities they’re staying in and various aspects to their care. There are so many layers to manage.

There’s also a huge problem with overbooking our physicians and medical staff. The patient volume is high, and they’re in and out of the hospital more quickly. The demands on a physician’s time are incredible. Physicians are constantly multitasking — being paged all the time, distracted, working long hours — with no time to sleep. The list goes on and on.

And yet the emphasis is on the individual doctor taking care of all the issues. You take these caring, smart individuals and put them in a situation where they’re overtired with too many demands on their time, and they’re supposed to double check themselves and make sure nothing slips through the cracks. Frankly there aren’t enough hours in the day to make sure you do all of that. You also don’t have the mental bandwidth to do it.

 

How did your experience change the way you practice medicine?

It changed how I view interacting with families. Last year I was an intern here at Brigham and Women’s. I was working extremely long hours and getting hundreds of pages I had to respond to. When I’d get a page that said a family wanted to talk, sometimes my heart would sink. I was tired, hungry and had other patients to attend to. It’s terrible. But you can get to a place where if someone asks you one extra question you’re just going to snap. That’s another example of burnout or being overworked. 

When I was first in the hospital with my mom I tried not to ask too many questions. I didn’t want to be labeled “difficult,” or as the daughter in med school who thinks she can dictate decisions. As a result my mom’s care got worse. I realized that we family members had a lot to offer, especially in terms of handoffs between physicians. Sometimes the only person who’s been present is a family member. In one case with my mom, a radiologist had picked a chemo drug he thought was best and later I saw a nurse begin to administer a different chemotherapy drug in response to his order. I questioned the nurse. The nurse was kind of annoyed, but she called the radiologist and then administered the correct drug.

 

What did you learn about patient safety as a medical student?

We had some lectures peppered throughout the curriculum. No patient safety course, but we had talks here and there. I went to med school because I was passionate about science and care, so the patient safety topics weren’t the most exciting. They were about organizational structure and felt more like business school than medical school.

I would have been more attuned to this problem if the instruction had been tied to individual patients. When I came back to medical school [after caring for her mother], I did a patient safety elective – which was a new thing at the time – where students sit in on committees that are reviewing adverse events. Reviewing those cases made it easy for me to imagine myself as a physician who missed something important while caring for a patient.

 

What’s one way medical providers can reduce the number of patients who suffer harm?

Sometimes errors are not even tracked. When I returned to medical school after my mom’s death, I found that there was no way for medical students to report an error. There was an error reporting system, but the medical students did not have a login for it. Myself and a couple other physicians in the patient safety elective helped get that changed.

And when errors are reported, the response is not always constructive. I filed an error report a few days ago about a medication event. Most people responded well, but a few emails I got showed some people were not happy being involved in an error report. We’re not all the way there yet. People are still prone to taking these things as personal failings instead of thinking about the system. We need to move away from a culture of saying ‘error reporting is done to be punitive’ to ‘it’s everyone’s job to error report to make the system safer.’

We need to build a culture of patient safety. That means removing the stigma from patient safety and error reporting so we can collect data about errors and learn how we can fix things. That’s better than not knowing the scope of the problem because people are afraid to talk about it. 

 

For more, see the story Goodman wrote for the American Medical Association.


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The shortage of physicians is artificial. The nation must fully fund medical education (along with undergraduate education of all types) and incentivise physicians who go into family practice. The nation cannot afford to do less. Even i we spend a $million on a physician’s education we will get 40 years of service to our populace in return. Create more physicians by removing the economic blockade and then get more physicians out there practicing. And hospitals and nursing homes need to be at the forefront of the evolution of medical care to the quality assurance and corrective action processes that made the Japanese electronics and automotive industries so efficient. We can have an effective and less expensive medical care system in the US if we embrace public funding of education and insist on corrective action processes in our medical instituions.

sharon jarvis

Jan. 9, 2013, 7:07 p.m.

Sounds like the solution is to avoid staying in a hospital at all costs.  And if you do have to go there, get out as fast as you can.

I’m not being facetious; I know numerous people, including my father and sister, whom were done in by medical mistakes and wrong diagnoses.

Great interview, but why is Dr. Goodman so unwilling to admit that the care providers were negligent?  Just because they did not intend to harm her mother does not excuse their failures, in the same way that a very good driver is held accountable for not seeing a stop sign, and causing preventable injury.

This must have been hard both during and after her mother’s death to speak frankly about the failures of the healthcare system. Thankfully, she does. Only when they are addressed, can they be corrected. And unfortunately, not every patient has family members who can be connected as she was.

And doctors have the gull to charge so much money!

Frank, you’re close.  Yes, the cost is obviously some part of the problem, but the shortage is even more artificial than you realize.  Even if Harvard Medical School was free and accepted anybody who applied, there wouldn’t be any additional doctors.

Nobody wants to talk about it because too many people feel they’re obligated otherwise (especially doctors, plus lawyers who have their own parallel system), but the AMA specifically limits the number of licensed doctors in a particular area.

(In fact, medical schools appear to be overly-selective and elitist so that a medical degree gives you a good chance at a job.  If everybody got a medical degree, most of us wouldn’t get a license, making it illegal to practice.)

The result is that doctors especially working in hospitals are overworked and overstressed.  And when any of us is like that, even when the situation isn’t life and death, we’ll repeatedly make stupid decisions when we should (and do) know better.

That’s why it’s important for doctors to get angry about what’s happening to patients.  Until they do, they won’t investigate why.

The AMA should be acting like a real union (instead of a guild) and demanding rules that get doctors the heck off the floor when they’re tired and/or prevent them from getting tired.

M. Shopper, M.D.

Jan. 10, 2013, 2:09 p.m.

When my son (at that time a 3rd year medical student) and my wife visited her ill mother at a Tucson AZ hospital, it was clear that mother was dehydrated, unable to take fluids by mouth, and receiving no IV fluids. After a phone consultation with me, I suggested that the attending be called absent any other coverage.  Since it was the Easter holiday the attending waited the two days before seeing her, at which time she was close to death.
  When my father was hospitalized with a fractured hip in 1977 at a prestigious university affiliated hospital in New York, they appropriately “pinned” the hip.  When urinary output was scant, an IVP was planned.  I was told that somehow he was given a huge and inappropriate dose of castor oil to cleanse out the gut prior to doing the IVP.  However the dose was so huge that the entire inner lining of the gut was removed, leading to massive dehydration and death.
  In neither case did we, as their children, bring suit, nor did the bereaved spouses.  Somehow, loss overrides retribution.

BabyBoomerWriter

Jan. 10, 2013, 3:36 p.m.

The AMA has been silent on many issues as membership numbers shifted. It was’t until recently the public was told that new doctors made more mistakes when they didn’t get proper sleep and rules had to change. Why haven’t doctors monitored their colleagues and openly fought against the license renewal of peers who were not practicing medicine appropriately or safely. What group has taken responsibility for ensuring professional excellence and patient safety?

BabyBoomerWriter, running them out on a rail isn’t the right solution.  That breeds fear, which is just as dangerous as fatigue.  Nobody has ever become more talented or less tired under threat of losing their job.

Good doctors treat the cause (the fatigue), not the symptom (the doctor who made the mistake), and that’s what they need to do here.

The solution is to send anybody home whose performance is at all questionable.  I don’t mean “fire them” send them home, but actually give them the day off until they can function.

But (a) you can only do that if you have doctors to pick up the slack without propagating the problem, and (b) expanding the market would cause income to drop, in turn making med school tuition crash.  So you’re not going to see any organization solve the problem.  It’s win-win for everybody except the big organizations that have the doctors coming and going.

Johanny Clarke

Jan. 10, 2013, 10:19 p.m.

I work in healthcare.  This is an excellent article.  Kudos and God bless this young MD and the journalist Marshall Allen for publicizing this issue.  Thanks also to the commenters (like John) who are pointing out that running health care workers on a rail is not the answer.  The problem is often systemic, meaning that it is exactly as Dr. Goodman says—most health care workers are not actually unkind, unknowledgeable, or even lazy.  (As in any industry, there are bad apples, but for the most part every one from the bottom up is working unbelievably hard in a setting, that frankly, may not be so attractive.  Think of a nursing aide, wiping poop. Would you want to do this for $10/hr? And frankly, one can make $10 hr as a sales associate at Macy’s….so people are actually choosing to be a in a care-based profession; and in fact, many of them are really quite caring.)

So back to the topic.  The problem is often overwork and poor safeguards—in fact little understanding of where safety issues might occur and even in case where issues are uncovered, a lack of will to fix the problems. In hospitals there are supposedly quality improvement (QI) initiatives going on all the time.  I suspect that these are mostly aimed at gaining grandiose titles like “MAGNET STATUS,” [which means that most of the hospital’s nurses are BSN trained (4yrs) etc, etc, or aimed at improving patient satisfaction (Press Gainey results).  As far as patient satisfaction goes, hospitals seem to have concluded that if patients THINK that a hospital is safe and friendly, it goes a long way to avoiding lawsuits…..(which is actually true) but doesn’t fix the underlying faulty structure that leads to the “Swiss cheese model” of mistake-making. 

Hospitals are under the gun from HMOs to be profitable.  As a result QI tends to be aimed at employees (to whom blame is often shifted) instead of at procedures.  In other words, mistake X happened because nursing aide Y didn’t follow policy NJKB #167re397, part B.  Yet, think how HELPFUL a mistake-catching methodology could be instead of relying on health care workers to be 100% on 100% of the time, despite varying work conditions, including exhaustion, overwork, a sudden overload of patients, high acuity that particular shift, and so on.  Is there ANYONE out there who is 100% on top of things, 100% of the time????  Not to mention a well-meaning MD or nurse given poor or inadequate communication handoff, so that despite every best effort by that healthcare worker, a crucial missing piece of information can lead to a mixup or disaster. 

Think of how many people have been saved by the practice of “TIMEOUT,” a process in which the team about to perform surgery, stops to make sure consent is given, that the correct surgery is being performed on the right patient, and on the correct body part!

Or what about the ongoing design flaw that is permitting similar tubing and connectors for feeding tubes and IV tubes, allowing nurses to hook up nutrition bags to pump right into patient’s veins?  It’s easy to blame an individual nurse for this, but isn’t this absolutely INSANE?  The tubing and connectors should be different, and this problem should be rectified immediately in every hospital around the country.  But so far, “though experts and standards groups have called for tubes with different functions to be made with incompatible connectors so that it is impossible to use a tube incorrectly, they have encountered resistance from the medical device industry and the Food and Drug Administration’s approval process, which does little to advance safety-related improvements”  (see http://www.fiercehealthcare.com/story/lax-regulation-tube-design-harms-patients/2010-08-23#ixzz2Hd2hHUTd).

Johanny Clarke

Jan. 10, 2013, 10:28 p.m.

I work in healthcare.  This is an excellent article.  Kudos and God bless this young MD and the journalist Marshall Allen for publicizing this issue.  Thanks also to the commenters (like John) who are pointing out that running health care workers on a rail is not the answer.  The problem is often systemic, meaning that it is exactly as Dr. Goodman says—most health care workers are not actually unkind, unknowledgeable, or even lazy.  (As in any industry, there are bad apples, but for the most part every one from the bottom up is working unbelievably hard in a setting, that frankly, may not be so attractive.  Think of a nursing aide, wiping poop. Would you want to do this for $10/hr? And frankly, one can make $10 hr as a sales associate at Macy’s….so people are actually choosing to be a in a care-based profession; and in fact, many of them are really quite caring.)

So back to the topic.  The problem is often overwork and poor safeguards—in fact little understanding of where safety issues might occur and even in case where issues are uncovered, a lack of will to fix the problems. In hospitals there are supposedly quality improvement (QI) initiatives going on all the time.  I suspect that these are mostly aimed at gaining grandiose titles like “MAGNET STATUS,” [which means that most of the hospital’s nurses are BSN trained (4yrs) etc, etc, or aimed at improving patient satisfaction (Press Gainey results).  As far as patient satisfaction goes, hospitals seem to have concluded that if patients THINK that a hospital is safe and friendly, it goes a long way to avoiding lawsuits…..(which is actually true) but doesn’t fix the underlying faulty structure that leads to the “Swiss cheese model” of mistake-making. 

Hospitals are under the gun from HMOs to be profitable.  As a result QI tends to be aimed at employees (to whom blame is often shifted) instead of at procedures.  In other words, mistake X happened because nursing aide Y didn’t follow policy NJKB #167re397, part B.  Yet, think how HELPFUL a mistake-catching methodology could be instead of relying on health care workers to be 100% on 100% of the time, despite varying work conditions, including exhaustion, overwork, a sudden overload of patients, high acuity that particular shift, and so on.  Is there ANYONE out there who is 100% on top of things, 100% of the time????  Not to mention a well-meaning MD or nurse given poor or inadequate communication handoff, so that despite every best effort by that healthcare worker, a crucial missing piece of information can lead to a mixup or disaster. 

Think of how many people have been saved by the practice of “TIMEOUT,” a process in which the team about to perform surgery, stops to make sure consent is given, that the correct surgery is being performed on the right patient, and on the correct body part!

Or what about the ongoing design flaw that is permitting similar tubing and connectors for feeding tubes and IV tubes, allowing nurses to hook up nutrition bags to pump right into patient’s veins?  It’s easy to blame an individual nurse for this, but isn’t this absolutely INSANE?  The tubing and connectors should be different, and this problem should be rectified immediately in every hospital around the country.  But so far, “though experts and standards groups have called for tubes with different functions to be made with incompatible connectors so that it is impossible to use a tube incorrectly, they have encountered resistance from the medical device industry and the Food and Drug Administration’s approval process, which does little to advance safety-related improvements.”

Amorette Allison

Jan. 11, 2013, 12:47 p.m.

My father was a physician who refused to belong to the AMA because he said all they cared about was making doctors richer rather than being concerned about actual healthcare. He’s been dead 30 years and nothing has improved since then, despite all the technological and pharmacological advances.

Belinda Pauls Anderson

Jan. 11, 2013, 4:01 p.m.

No doubt, being human, mistakes have and always will be made. The first line of defense is to as a family member and/or patient be aware of the facility you or a family member is a patient in and to spend time (if a family member is unable to do so; an advocate for the family who is given access and permission to advocate on behalf of the patient) observing. My mother was a patient in a hospital for 46 days and although it was exhausting, I spent everyday there…made sure that medication were given in a timely matter and were correct (you cannot rely on the scanning system designed for eliminating errors…they are machines and people have to enter the information in them so you need to look at the medications and if they are not what you think it should be…challenge it before given, I asked questions…lots of questions,  I was there to speak with her physicians daily and had no issue with having them paged if I needed, I knew all of her vitals for every shift (for the night shift since I was not allowed to stay I was sure to check the following morning…anything that I felt could help ensure that she was receiving the best care, I did. I know I was labeled by some as a problem or busy body but that did not matter to me because it was my mother’s /life that was my first concern. When they came to me telling me that she was being discharged on a Friday…I told them…that was not an option…Friday discharges should not be allowed. They do them because of lower staffing on weekends but when you take a family member home (especially after an extended stay) you set yourself up. If anything happens after 4pm on Friday…there is no one to call for assistance. More than likely the PCP office is closed so the only option you have is a long stay at the ER. When it was time for discharge I made sure that medication list were accurate, if there was any home equipment/services needed they had been ordered and I utilize the social workers to the max. I understand that staffing is a problem and everyone in the hospitals are overworked but when it comes to my loved one…that is not my problem…that is an administrative problem and I have no trouble in letting them know. Any problems I encounter are report to first the Patient Advocates office and if they are serious enough to the hospital administrator…directly by me. I am HARD CORE when it comes to the care that my loved ones or myself is to receive in any facility. I have worked all my life in the field so that gives me a heads up but anyone can learn how to advocate for their loved one. For folks who are not able to invest the time…I suggest investing the dime to hire a private advocate….don’t rely on those who work for the hospital because they have a certain loyalty to that facility.

Thank you, Dr. Goodman for telling your story.  I don’t have confidence in the medical treatment of cancer.  I am high risk for cancer and carry the BRCA 2 gene mutation.  Although not in medicine I have researched cancer for over a decade and my research tells me they are suppressing the science for treatments that cure and diagnostic tools that detect cancer early.  I now believe that most medical providers follow standard protocol indoctrinated by the pharmaceutical companies in academics and research and I am committed to getting the medical community to recognize the predatory environment that you work in and exposing the corruption in medicine. 

The FDA, the CDC and the NIH appear to work for the pharmaceutical companies where profits come before patient safety.  What is medicine doing to address these concerns that patients like me are having regarding predatory medicine?  For background I have been poisoned by gadolinium based contrasting agents that were injected into me for screening MRIs.  I’m totally disabled now and didn’t even need the MRIs as mammography and breast ultrasound would have detected approximately the same amount of cancer according to my radiologist.  And proteomics with the first test being Ova1 has the potential to detect any disease non-invasively.  The company Correlogic went out of business and many like me believe it was because for no reason the FDA regulated the test and proteomics as a medical device.  The technology was available in 2002.

I’d like to think that, after the publication of this article, in, say, about six months time, Marshall Allen will report that Elaine Goodman has been contacted by two or three senior players in the US healthcare system, inviting her to join in a collaboration which has the serious intent to improve standards of safety & quality. I mean, Goodman is a treasure to be nurtured, not left to hang out & be picked off.

This brings back painful memories of our own family’s experiences of flawed medical care on more than one occasion in one of the most prestigious hospitals in the country, leading to terrible long term consequences. Our solution was to pay for the best private duty aides and nurses and close family involvement to supplement the care in the hospital, and later in skilled nursing facility, and the expense was enormous but necessary and the right thing to do. 

I sympathize with Dr. Goodman, and also with the political choices she must have faced, and must face every day as a doctor, being as she is subjected an unspoken medical “ormerta” or “code of silence” and the backlash and blacklisting she would face if she were to criticize the hospital or its practices, while trying to help her mother heal and live in dignity.

Has anyone in the medical profession looked at the airline industry’s ever-improving safety record for guidance?  About thirty years ago, in response to a steadily increasing accident rate, the FAA and industry began to create what has now become the Aviation Safety Action Program (ASAP).  It’s a self-disclosure program that, critically, provides the reporter with protection from punitive action from the FAA or their employer.  This program (and, of course, technological advances) is largely credited with making airline travel safer that riding on an escalator.  Why wouldn’t this work in the medical field?  Combine this idea with actual health care (as opposed to our current money-controlled sickness care system), and we might actually make some headway.

I love how nurses are only mentioned once in the article. Who does the public (or a medical student) think are REALLY taking care of the patients? Dr. Goodman believes the entire burden is on doctors. What a laugh! Nurses are at the forefront of caring for patients, and they’re overworked and understaffed. They’re not allowed to practice to the full extent of their education (which in many cases rivals that of a med student).

Today’s nurses (at least in bachelor’s degree programs) take basic courses like anatomy and physiology right alongside pre-med students. Nurses can play a much larger role in preventing DOCTOR errors and solving problems (you think the issue of lookalike cords, IV lines, and medication labels is NEW to nurses??) if only hospital administrators and doctors would support them.

Smart medical students and residents understand a good nurse can be one of their greatest assets in patient care. A good nurse can save a resident’s ass. It’s pretty evident from the article Dr. Goodman isn’t among the med students who understand this, to her detriment.

Natalie-  How right you are.

It’s encouraging to read that physicians are taking responsibility for safer practices and better patient safety. However, as long as each health practitioner is working within their own bubble, communication between doctors, nurses, pharmacists, oncologists, patients and their families will continue to be distorted.  What might be lacking is the acknowledgement of expertise that resides in each practitioner, the patient and their carers (families and friends).  Engaging a patient in their own health care by consulting more about what is best for them, based on their values, beliefs, best practice approaches and research evidence will go a long way in the healing process that is necessary not only for the patient but for all involved in the patient’s care.  It also encourages the patient to take responsibility for their own health care so that the load can be shared among a team of health professionals.  In the rush to see as many patients as possible, it is easy to dismiss the emotional needs of a patient and that the interaction between doctor or nurse and patient can be a mutually beneficial synergy, rather than a detached and hurried consult that is easily forgotten.

Paediatric oncology care is definitely on the right track with many centres working with child and adolescent patients as multidisciplined teams, which include all types of practitioners and the family working together to determine the best way forward for the patient.

Just as drivers are encouraged to get off the road and take a nap if tired to promote better road safety, the same rules should apply in hospitals with overtired/overworked doctors and nurses.  As we’ve seen cars/trucks and medication are both vehicles for lethal outcomes if used less consciously.

Todd Miller, Ph.D.

Feb. 6, 2013, 9:54 p.m.

Great article and her experience is not atypical.  The young physician may not realize what all the problems are because she’s only worked in a US health care system.  The reason things are complex as she puts it is the profit system.  Sure they corrected the problem after the fact but I bet if you went back to that hospital, some of those safety protocols and changes have been rolled back.  The problem isn’t with our health care professionals it’s with a system that spends its effort containing costs and then sometimes as an afterthought but I also can pretty much guarantee that when the committee was discussing how to prevent the next, somewhere in the hospital or the government a regulations or protocol was being rolled back because it was too burdensome (AKA too unprofitable) for medical staff.  It’s like a dike with thousands of leaks in it and only hundred doctors to put those leaks into a thousand holes and the Chief Medical Officer is somewhere else investigating how they profit more from the hydro-electric plant.  Somebody is going to get hurt until to change the incentives within the system.

This article is part of an ongoing investigation:
Patient Safety

Patient Safety: Exploring Quality of Care in the U.S.

More than 1 million patients suffer harm each year while being treated in the U.S. health care system. Even more receive substandard care or costly overtreatment.

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Too many patients suffer harm instead of healing in U.S. medicine. That’s why ProPublica’s reporters have investigated everything from deadly dialysis centers and dangerous hospitals to the failure of state boards to discipline incompetent nurses.


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