ProPublica

Journalism in the Public Interest

Cancel

Why Can’t Medicine Seem to Fix Simple Mistakes?

The death of 12-year-old Rory Staunton from septic shock prompted NYU’s Langone Medical Center to revamp its emergency room procedures to address a startling lapse. History shows that the profession is unlikely to learn from this mistake.

« Return to Story

Sort by: Oldest Newest  <  1 2

Diane Haugen

July 22, 2012, 4:19 p.m.

Yes, Joe.  Enough. 

I prefaced my remarks with the caveat that my viewpoints are not mainstream.  But that makes them no less notions worth considering or discussing in a forum like this one than anyone else’s. 

We have agreed to disagree.

Thank you for taking the time to provide your perspective on my perspective.

bernadett

July 22, 2012, 4:26 p.m.

Added to the salient comments by other nurses, I always wonder why we’re never part of the discussion. It seems to me that commentary is always top down; I wonder if these opiners have any idea what it’s like to work in a patient setting.

Joe

July 22, 2012, 4:29 p.m.

I think a critical point is being missed. No matter how much you well intentioned people get done. In the end you are going to have a monopoly. 

For example:
During free market dentistry,  the precursor to the ADA knew that mercury was dangerous to put into peoples mouths, and prohibited it. In comes the monopoly ADA, and mercury is put into children’s mouths for 5 generations with no other choice because the ADA has a monopoly on dentistry in this country. 

I am mercury toxic and poisoned BTW. I was never given a choice like we all should in a free society.

cacachee

July 22, 2012, 5:44 p.m.

I have found the comments interesting. As a person who has lost a family member to malpractice in my life I find the Congress and the AMA rediculious organizations.when it comes to doing anything about mal practise.  In 1985 the Orlando Sentinel did a report on medical
malpractice in Florida. The found that 78% of the malpractice suits were against 3% of the doctors. There are, for obvious reasons, who should not be child care workers, or police officers, or fly planes etc.  There are people who should not be doctors, nurses or in other fields having to do with health care. I lost my only son in 1982 to malpractice.
We found out later that the doctor had been sued at least 3 times before our lawsuit. During the investigation a RN who worked for the lawyer discussed the case , under cover, with 23 doctors of the same field. Every doctor said that our doctor screwed up big time. The RN even discussed the case with a medical professor at Emory University. He also said the doctor screwed up.  Not one of these people would testify or even pertisipate in any way against the doctor.  After one and a half years our lawyer told us we would have to go outside the state to get a doctor who would be willing to come to Atlanta to testify. We had to agree to pay the doctors expenses and a fee. Only then did the other side want to sit down and talk about a settelment. I didn’t want money I wanted the doctors license. My lawyer told me I would never get a doctors license. Everything in a lawsuit is converted to money. The hurt, the pain, the anger, the loss, it all is converted to dollars.
Sense the victem was a child and had no income potential, the settlement was not enough to persuade the doctor to take care next time he was late for a tee time.  The doctor later became famous in Atlanta for botching a operation on two infant boys and having to perform sex change operations on them. I can only hope he suffered at the time of his death.
Now within the last 3 months I have lost my wife of 44 years to a malpractice situation. A operation that should have not taken place. Records lost at the hospital.

I have watched over the last 20 years at the progress of malpractise. There has been no progress for the victims. During the Bush years when the Republicans were in control they tried to pass a law that would make it illigal to use a out of state expert in a malpractice case.
I don’t know if it passed or not.

Doctors are no more willing to testify now than they were 20 years ago.
They also passed a law requiring the lawsuit to be filed within two years of the incendent.

Doctors hire insurance companys so that they do not have to accept personal responsibity for there mistakes. The insurance companys tell the doctors that once the suit is filed not to contact the victim. The lawyers who represent the insurance companies are there not for the doctor. They are there to represent the insurance companies. They have a responsiblity to the stock holders of the insurance company to protect the profits of the insurance company. Therefore they try to resove the problem as low cost to the insurance company. They could care less if the victim has a life long result of the malpractice.

The republicans always talk about taking personal responsibilty. They do not mean corporations, LLc, or any business. They want you to take responsiblity. That is the main reason people incorporate so that they can protect there assets frorm the mistakes that they make as people.

Free market can never be it he healtcare field as long as the congress interferes with malpractice laws through tort reform.  The awards must be suffient to persude the medical establishment to change, get ride of doctors who over years continue to perform malpractice.

Joe

July 22, 2012, 6:33 p.m.

I am sorry for your loss cacachee.

Malpractice is actually accepted and practice when it comes to many things, one of them being putting mercury into the bodies of their victims. I have been sick for 40 years, and many days wish that they had killed me instead.  There is nothing I can do since poisoning people with mercury is a standard part of the medical monopoly.  It is the monopolistic nature of medicine that protects this priesthood.

cacachee a legal system where people are responsible for there actions is an integral part of the free market. We do not have it. Vaccine manufacturers are totally exempt from any damage that their vaccines cause. This is not free market.  A free market would also get rid of bad doctors much better than the license monopoly. In a true free market someone could collect data on doctors and publish it on a web site. The way things are now the government hides this data to a large degree.

We don’t need congress in medicine.we just need freedom. The freedom to make medical choices and a legal system that we have access to and that works. We now have neither.

margaret reeve panahi

July 22, 2012, 11:05 p.m.

I am so glad to hear other voices on this-it is a huge nation to manage health care in.  I would suggest that profit motive is in our place and in our work and has caused, pain and reduced care from the nurses, support staff, lab specialists, ED staff, and we are all feeling the pressure to reduce care. Administrative time is about 30% of our time as practitioners off the top.  The push to reduce care is scary and I am personally still trying to GET care to so many who don’t have any, or nearly enough.
I think that big pharma and medical business has created this, Doctors have bought into it, to a certain extent, nurses have been constrained more and more and all of this is co-existing and fighting for crumbs.  I worked in a complex medical team for high risk patients, and it worked well, but funding was cut. 
I really do think that the power of money is driving what we have and the medical staff are not happy about it.  I read that 60% of the mD’s would like a single payer system for our country. Everyone knows that it is cheaper and gives better care all over the world.  We are bound by big money now, which is running our once beautiful system into the ground. I think that very few people like how this works, aside for the wealthy directors of the funds.
  There are many other health care systems in the world which have protections for their citizens, and from that common knowledge, it would appear that those who are dissemination the money for care here in the USA don’t care about the human lives and strength of our citizens in any way, except to profit from it.

Matt Deen

July 23, 2012, 12:57 a.m.

This is a great story of enormous importance. I’d be curious to know what impact, if any, tort reform in the U.S. has had in contributing to higher incidents of negligence and malpractice (if, in fact, there have been higher incidents of such since its passage).

Joe

July 23, 2012, 7:53 a.m.

margaret reeve

The profit motive is not what causes all of these problems. The profit motive is what has brought us all of the modern wonders that you see around you.  What causes the “problems” -  are individuals that choose criminal actions, and a legal system that is not prosecuting them. Also a captive audience because of the monopoly nature of medicine means that you and I can not vote with our feet and choose systems that care about patient safety. It works with every other service we buy.

For example:
If one hotel chain does not take safety seriously and their hotels burn down and kill people. Guess what?  In a free market we take our business to another hotel chain! But not with monopoly medicine.

Yes there is pressure to make a profit!  Would you work for someone that could not make the payroll?

If you take a close look at what is going on,  the reason that costs are so high is because of government involvement in heath care.  People calling for the people than caused the problem to solve it are ill informed as to what the problem is. 

We are a brainwashed people that are taught that the free market is the cause of all of our problems while the exact opposite is the truth.

Hitlers propaganda minister Joseph Goebels said that all you have to do is to repeat a lie often enough and the people will believe it. Oh how true that is in this case.

Mark Zeidel

July 23, 2012, 8:38 a.m.

Many hospitals, including ours (Beth Israel Deaconess, Boston), have institited systems designed to avoid these errors.  They include (but are not limited to) protocols for managing presumed sepsis, checklists and time outs for surgical procedures, early warning systems to detect patients who are becoming unstable, and strict adherence to protocols to avoid central line and ventilator-associated infections.  It is critical to cultivate a “culture of quality,” in which front line staff call out problems, and these call outs lead to well considered efforts on the part of everyone to avoid errors.  Pro Publica could do a real public service by going to these hospitals, and describing in detail the systems that appear to be working.  You can identify these sites by looking at reports from the Leapfrog group or IHI.

Kathleen

July 23, 2012, 9:57 a.m.

This has happened to me more times than not after my initial diagnoses’ and surgeries starting in 1985. It has been a nightmare! From misdiagnoses to making terrible mistakes in the surgery room it is an act of God that I survived the doctors. In 1985 my first diagnoses was a thyroid condition. One that I told each doctor my mother had it. Four doctors told me I needed to; lose weight, get a hobby, see a psychiatrist. Several doctors later (a woman) I was diagnoses with the same thyroid condition as my mother. THIS was just the beginning! It only got worse to near death from a misdiagnosed but COMMON genetic blood condition called hereditary hemochromatosis. Several doctors refused to believe that my swollen failing liver was not from drinking. Oh and doesn’t end, I just went through months of needing a simple cpap machine, did the sleep study, was advised I couldn’t breath and sleep at the same time. It took MONTHS of suffering because the office staff didn’t seem to be able to use the fax machine. I actually had to change doctors to get the machine. There are serious problems in the medical field, hospitals are not safe places. Last year my husband nearly died when he had his gallbladder removed at the VA hospital in Loma Linda Ca. They accidently cut his main billiary duct, drugged him up for pain and sent him home.

Tamer Acikalin MD MBA

July 23, 2012, 10:17 a.m.

There are methodologies and books written about performance improvement. One of the books is “Performance Improvement for Healthcare: Leading Change with Lean, Six Sigma, and Constraints Management” see my review: http://www.amazon.com/review/RSIO57WC5YDR.

Hospital management is the responsibility of hospital administrators as well as physicians. Medical errors are systemic problems and thus should be dealth with systemic solutions. Everyone focuses on physicians when medical errors occur. Lest not forget the system that they work within.

Annette

July 23, 2012, 10:25 a.m.

Staffing is a huge part of it.  Hospitals staff to be “efficient,” but that leaves too little staff when things get hectic.  I’d give away a lot of the machines if staff weren’t so harried and had the slack time to actually DO a good job.  When you drive people to their limits, they make mistakes.

But every corporation fights tooth and nail against any sort of minimum staffing requirements.

Also, nurses work super-long shifts and sometimes they work them back-to-back.

It’s really sad.

joe

July 23, 2012, 10:37 a.m.

OK Annette it’s sad that we live in the real world and the medical industry has some of the same challenges as other business’s. 

When are we going to address the real causes of the medical industry’s problems and the solutions? 

A hint. The causes are the same as in other business’s, and the solutions are also the same.

Diane

July 23, 2012, 10:52 a.m.

Where’s the evidence for what works?  I run a statewide mandatory error reporting system, working for my state’s health department.  Hospitals are required to report when certain errors occur, required to do a root cause analysis, required to put a correction in place.  We see increased compliance with best practices, and some areas in which there is progress (falls prevention, in particular).  But we still see things happen that shouldn’t be happening anymore.  Pre-surgical time outs don’t happen.  Patients still are allowed to mark the surgical site…and they mark the wrong one.  Pressure ulcers are seen as unavoidable complications.  Staff are too rushed.  People are afraid to speak up.  Physicians are allowed to circumvent processes that they don’t like - or the process is warped to the point of ineffectiveness during its development in order to accommodate one or two stubborn docs who don’t want to follow it.  Human errors (which are inevitable) still hit the patient, and system-based fixes aren’t in place.  So what do we do?  We focus here on learning and transparency….but what do you do when that’s not enough?  I don’t believe that issuing massive fines on hospitals where errors occur is the right answer - that just drives reporting underground.  But what’s the right balance of carrot and stick?

Diane

July 23, 2012, 11:08 a.m.

“The profit motive is not what causes all of these problems. The profit motive is what has brought us all of the modern wonders that you see around you.  What causes the “problems” -  are individuals that choose criminal actions, and a legal system that is not prosecuting them.”

I would respectfully disagree.  As I noted in my previous post, I manage a statewide mandatory error reporting system.  I have 10 years of data from my state, on all kinds of errors.  I don’t think that the profit motive is behind all of them, but nor do I think it’s about individuals that choose criminal actions.  I’m speaking from the actual data, not from preconceived notions (or political biases).

Quite often, the way that the profit motive/desire to cut costs manifests itself is in rushing to see more patients and do more procedures.  Many times, we see safety procedures that are shortened, steps that aren’t taken, patients who are rushed in or out of a procedure room without waiting for test results because the next patient had to get in, etc.  We also see cases where staffing wasn’t appropriate - not too often, but sometimes - and cases where frontline staff have pushed to get certain equipment or tools to help them improve safety but they aren’t able to get the resources they need.  Safety units in hospitals are often thinly staffed - not enough people to do meaningful investigations or to make sure that corrective actions are implemented.

As for criminal action - sorry, but no.  Sometimes there is criminal activity, but the overwhelming majority of the time errors happen because someone took a shortcut with no intention to harm.  They were rushed, they had other patients to see, they didn’t think they needed to check the patient’s ID because they knew who the patient was, they misread a label, etc.  Criminal activity related to patient safety is exceedingly rare.  And one of the reasons why it’s not prosecuted when it happens is not because of our legal system, but because the hospital itself doesn’t want the bad press.  So if a doc or pharmacist diverts controlled substances for their own use, the hospital will either just shunt them into a treatment program or counsel them, and often won’t cooperative with law enforcement to investigate because they are afraid of how they will look (and afraid of lawsuits).

Joe

July 23, 2012, 11:36 a.m.

OK Diane I am going to try once more. :—)

You SAIS :I would respectfully disagree.  As I noted in my previous post, I manage a statewide mandatory error reporting system.  I have 10 years of data from my state, on all kinds of errors.  I don’t think that the profit motive is behind all of them, but nor do I think it’s about individuals that choose criminal actions.  I’m speaking from the actual data, not from preconceived notions (or political biases).

***  You fail to address the crucial fact that there is no competing system to the existing system so that people are not trapped with a bad system. Don’t you think that market force would tend to eliminate errors?

The statement “I don’t think” is not 10 years of “data”.

There are repercussions for people taking shortcuts. You do not address that a failing of the court system encourages this behavior and needs addressed.  There are civil actions that can be taken for “shortcuts” (negligence). And even criminal prosecutions. You do not have to have criminal intent for such crime as negligent homicide. It is entirely possible to have both civil and criminal prosecutions where appropriate for “shortcuts.”

That there are not witness’s willing to talk is BS. Every other type of crime is prosecuted even when witness’s do not want to talk. Am I to assume that doctors are cunning criminals that can get away with crimes while no one else can?  If something is broken in the legal system fix it instead of addressing everything BUT the real problems.

If I were to start a free market competition with the current system one element of it would be to document everything so well using video, audio, etc. that there would be no need for witness’s to testify at all, as all of the necessary evidence would be there…. 

The problem is that peoples minds are stuck inside of a very small box when they consider that is possible.

” Some people see things as the are and ask why?
I see things as they never were and ask, why not?”
~author unknown

Open your mind and consider the later. Logic is not a political bias.

Andy M

July 23, 2012, 11:43 a.m.

Hoorah! Thanks Tamer and Mark - (see my previous comment) just as the discussion was devolving into references to Hitler and Goebbels and irrelevant anecdotes..a little light!

Heartening to read so many reasonable people asking “what is the solution?” Any solution is, and must be, evidence-based. Pro-Publica’s ‘Patient-Harm’ complaints department will not help it will just generate more anecdotal fodder. If you came to harm in a hospital, call the hospital Risk Management department and get a lawyer. If your case has merit, Tort law is the remedy this country deems the most appropriate to make those hurt, ‘whole’. That’s the whole point of Tort. It’s not about revenge and it’s not about punishing the physician who in the vast majority of cases does not act with willful recklessness or neglect. Studies show that by far the most guilty miscreants are systems and processes that do not adequately provide for checks and balances to mitigate against known human factor potential points of failure.

Diane

July 23, 2012, 11:54 a.m.

Joe, I’ll try my best to stay on the high road here, and ignore the confrontational tone (and lack of data) in your posts. 

You want criminal prosecution for every shortcut.  So, every time that a physician or nurse fails to wash their hands, or fails to check a patient’s wristband, you’d like to see them criminally or civilly prosecuted?  What’s your estimate of what that would cost?  Even if we limited it to cases of harm, how would our current legal system - and penal system - absorb all of those folks?  How much are you willing to pay for all of the new jails we’re going to need?  In my state, failure to wash hands or sign a surgical site is not against the law - so the legal system isn’t failing to prosecute…they have no basis on which to prosecute, as the laws don’t exist.  If you were try to enact such laws, the lobbying muscle that hospitals and physicians would line up against you would be phenomenal.

As for competition - I don’t know what state you live in, but in my state we have dozens of hospitals in the major metro area, and most health plans contract with all of them.  That means that most people do have a choice of where to go for care - and they can choose to go to alternative providers, too.  We have transparency on quality and safety, so there’s abundant data out there to help people decide where to get care, and we require health plans to use that information in tiering providers, so that consumers are encouraged to choose providers who offer high quality, safer care at lower cost.  Hospitals compete with each other all the time - on quality, safety, patient experience, the latest high-tech equipment, etc.  If they didn’t think patients had the ability to move from one to another, the highway between my house and my job wouldn’t be full of hospital billboards.  As for whether we need an “alternative to hospitals,” what you’re talking about is just a hospital with more surveillance.  I fail to see how that’s a different model (just ask the RI hospital that has been required to videotape every surgery for the last 2 years).  But I would love to see how many people you’d find to come and work in such a place!

Re: the question of witnesses - I didn’t say there are no witnesses.  I said that hospitals choose not to alert law enforcement because they don’t want the bad press associated with having a drug user on staff.  And they don’t want to lose the revenue that those physicians bring in.  This is particularly a problem in rural areas - if you lose a doc (because he/she is behaving appropriately, is disruptive, etc), you can’t provide care and you’re not bringing in money.  There have been plenty of stories in the paper about that in my state, and presumably others - nurses or doctors who are allowed to continue to practice for years despite being known diverters, much like pedophile priests were shunted from parish to parish.

Joe

July 23, 2012, 11:57 a.m.

Andy your ad hominem attack is the only thing I see as devolving here.

If you have an issue with something please address it rather than resorting to such tactics.

Diane

July 23, 2012, 12:03 p.m.

“Studies show that by far the most guilty miscreants are systems and processes that do not adequately provide for checks and balances to mitigate against known human factor potential points of failure.”

Andy, I agree, but what do you do when, over the course of years, those systems don’t develop?  As I said, in my state we’ve been working on this for 10 years.  We’re non-punitive, we focus on learning, we bring hospitals together to teach them about best practices, human factors/system design, we follow the just culture model.  And still…..10 years later I see situations where the known best practices aren’t in place.  Not just situations in which someone took a shortcut from that known best practice, or where a human error occurred, but situations where those things that we KNOW will make care safer still aren’t happening. 

We talk about culture change, talk about leadership engagement, etc….and there too, we have a major statewide initiative working on this.  But what do you do when all of those efforts…..aren’t leading to culture change?  Or hospitals say that they’re doing it…but on the ground it really isn’t true.  We focus on the carrots, on the nice approach, on collaboration and non-punitive approaches.  But when does it become time to say that we need more teeth behind those efforts?  And what are those teeth?

Andy M

July 23, 2012, 12:03 p.m.

I’m sorry Joe, I didn’t realize you were in charge of making the rules here.

Joe

July 23, 2012, 12:04 p.m.

I can see that I am wasting my time Diane. You are reading things into my posts that are not there.

You fail to see that there is NO competition in most anything in this country.  Having a choice of 50,000 AMA doctors is NOT competition.  Having a choice of 5 hospitals that are regulated by the same agencies is not competition - just the illusion of it to placate people that are not really paying attention.

One does not need data to present logic. The logic itself is enough.

Diane

July 23, 2012, 12:23 p.m.

Joe, I’ve been trying to have a polite conversation with you, long after others have given up.  I’ve answered your questions and provided my own rationale and evidence.  All you’ve done is disagree and throw insults, while providing zero basis for your opinions other than that they are your opinions.  If you don’t want to engage in a conversation - or provide any data/evidence for any of your assertions, or any answers to the reasonable questions I’ve posed beyond continuing to insist that you’re being logical and therefore don’t need evidence (?!?), then I’m not sure why I’m still trying. 

Happily, there are plenty of people here who do want to have a real debate and discussion.

Andy M

July 23, 2012, 12:47 p.m.

Diane - As you know,  it’s a long, hard slog. Only now, after fifteen years or so in the business do I feel like the tide is turning. Some say it’s a generational thing. As the ‘old School’ docs and nurses reach retirement age, they are being replaced by highly motivated, tech (and systems) savvy individuals who are exposed to concepts of patient-centered care and understand how standards, systems and processes can be bought to bare on the industry.

My first hand experience also suggests that the young docs are not so egotistical (give them time, I suppose). That said, there’s an emphasis on the care-team as opposed to the doctor being in charge.

Unfortunately, I fear for some institutions, it will take an avoidable devastating tragedy to occur before the light goes on. For us, it was the Betsy Lehman case (http://www.mass.gov/eohhs/gov/departments/dph/programs/betsylehman.html) that put us on our current path.

We continue to improve our software systems that prove their worth on a daily if not hourly basis - but as you suggest that’s only part of the battle. The biggest hurdle is culture change and Change Management.

We are in the process of putting our employees - clinical, admin, IS—in both of our large AMC’s and the community hospitals and physician groups that service our patient community of 6 million, through a Change Management course based on Lean principles. This is giving us all a common vocabulary and a common frame of reference (and common vision) to work through the changes that must be made.

I am confident that all clinicians (except for the marginal characters) want to do the best right thing for their patients. Given that, the change, in principle is small (change “I’m going to do what I think is best for my patient” to “I’m going to do what the evidence says is best for my patient”)—however, in practice - it’s a lifetime’s work. Good luck in your en-devours and fight the good fight! You never know, they might write an article about us one day!

Diane

July 23, 2012, 12:54 p.m.

I will make one final try, though. 

Joe, can you lay out a few bullet points on what your solution is and how to achieve it?  You talk about lack of competition - okay, what’s the fix?  What’s the parallel system you’d create, and how would you do it?  How would it be different?  You talk about criminal/civil liability….okay, again, what’s the fix?  What’s your 5-point or 10-point solution?  Not just reiterating what you see as the problem, or complaining about gov’t interference or bad docs or whatever, but the actual specific policies that you would put in place to fix it.

Joe

July 23, 2012, 1:04 p.m.

“...Joe, I’ve been trying to have a polite conversation with you, long after
others have given up. I’ve answered your questions and provided my own rationale and evidence. All you’ve done is disagree and throw insults,.........Happily, there are plenty of people here who do want to have a real debate and discussion….”

I guess the kind of debate where no one disagrees?  That makes no sense what so ever.  It sound like you   want a mutual admiration society.  A place where disagreeing is throwing insults.

Philosophy does not require “data” how do you provide ” data” with a statement such as “All men are created equal…”  This is a self evident axiomatic system. 

Why do you keep insisting that I do the impossible? 

And when I don’t agree -  I am insulting and not participating in “real debate”.  I think the shoe falls on the other foot.

Ron Wright

July 23, 2012, 1:14 p.m.

One study suggests that in Great Britain, the rate of professional error is about 12%, Basic competence, work pressure, and lax procedural protocol are too common. Tort reform, snort reform ... keep ‘em sue-ing!  There are no available anesthetics for pocket-book pain or professional disgrace.  Nor seldom a protection against ‘the code of silence’.  As a comparison, one has only to know the number of convicted felons still practicing law and serving as active duty police personnel, to say nothing of other areas of public trust. “Knock! Knock!”
“Who’s there?”  “Just us people ...

Diane

July 23, 2012, 1:22 p.m.

Joe - sigh.  I give up.  I’ve asked you to prove your assertions, you say that philosophy doesn’t require data.  I give my opinions and provide the rationale, you say I’m illogical.  Others try to press you, you quote Goebbels.  I ask you for your solutions….silence.  I ask you again, you say that I must only want people to agree with me.  I don’t care if you agree with me or not, I’m simply asking you to provide evidence for your assertions and to tell us your solution.  Isn’t that what people do in the course of an adult conversation?  This isn’t philosophy 101, this is (or I thought it was) a discussion about how to solve a problem.

Michael Sieverts

July 23, 2012, 6:21 p.m.

It would behoove everyone to read Gawande’s January NYer piece:

http://www.newyorker.com/reporting/2011/01/24/110124fa_fact_gawande?currentPage=all

Vince Gay

July 23, 2012, 7:15 p.m.

There really are three major categories of mistakes (though, if you’re at the receiving end of one or more of them, you probably don’t much care about the category):

One category is the isolated human error by someone working conscientiously.

Another category is egregious sloppiness like what we see described in some of the stories in this piece.

I have a question, one to which I do not claim to have an answer, about a possible third category:

Given the hot-dog culture (and a litigious larger world) that mediates any admission of fallibility among many in the medical field, how could someone who formulates procedures or manages operations truly know if a facility was short-staffed, if the staff in a medical facility simply had too much on their to-do list, were being asked to track too many details at once, and/or were working too many hours? 

I worked in the less demanding field of residential care, and our facility forbade having too low a staff-to-resident ratio, and forbade more than two shifts in a 24-hour period because allowing these practices made the potential for dangerous mistakes and miscommunications unacceptably high.

I’d be interested in how medical professionals would answer my question.

Veronica James

July 24, 2012, 6:27 a.m.

I think a major road block to improving safety is lack of transparency and not following the reporting laws, complicated by the overuse of blanket gag clauses in settlements.  Please see here why these clauses are in fact ILLEGAL:

http://www.jdsupra.com/post/documentViewer.aspx?fid=ec220299-34be-4548-82a2-7574f360b64e

To wit, please sign and share:

http://www.thepetitionsite.com/426/911/456/end-the-silence-ban-gag-clauses-in-medical-settlements/

Thanks.

bernadette callister

July 24, 2012, 9:59 a.m.

HERE HERE MYRA I agree whole heartedly with you about the knowledge base of graduate nurses and the shift to “support staff’ and who have basically no training and end up being a burden on nurses. There is so much politically motivated decisions among administration for the purpose of maximising the profit margin of whatever institution. We need to have our own conversation about what we face everyday as licensed professionals and become more vocal.

Melissa Seminara

July 24, 2012, 5:28 p.m.

First, I commend ProPublica for the article..reporting any major medical error that could have been prevented can do several things….start a discussion & maybe lead to help/resolution, it can open eyes to what is STILL going on despite the checklists SAID to be implemented or posted real pretty in hospitals (yes some do but in my experience very few are followed), it can open the door to write more articles of injured patients where they could actually still be helped (me being one of them where we didnt die yet & theres still opportunity for resolution), maybe these articles will force agencies or governing (political) organizations to see there are more instances & finally implement change, i could go on & on but reporting does help.  I also relate to who said ok so its reported now what do we do to change, Some steps have been taken but as a whole the current system/policies/structure in place has improved very little & errors have increased. Anyone who is involved in it from a business standpoint may see one thing but see it through a patients eyes/advocates eyes & you will see the truth.  I say that from eyes who have been both I worked at several major top hospitals in a large city on the business side & sided with the doctors I thought oh these issues must be isolated then THEN THEN I got sick & i was the patient - what i saw/experienced- there is no horror movie out more shocking.  I had a baby via csection & have been sick since.Prior I was a healthy, happily married, professional woman,  always on the go.. For almost 9 years of hell i was sent from doctor to doctor hospital to hospital diagnosed & treated for almost everything you can think of & some of them very serious which required serious treatments only to be told its none of that it all stems from your delivery you have a foreign body left in you ..after further looking .. it showed up on a scan a month after your delivery & it was misread as a tampon..still after further imaging was done it was read as a liver lesion or a hypoattenuating structure, etc everything but the sponge it shoud be read as, doctor after doctor “thats impossible there are markers it would have picked it up” come to find out after years the markers become twisted, it can migrate it can dissolve & BTW the markers get confused & interpreted as contrast or surgical clips.(reference judge bailey retained sponge september 2010 MSNBC no test picked it up & that was right after surgery not years later of it rotting in you).  Currently i cant find a surgeon to do the surgery required some have attempted laparascopically & cant reach the areas the laparotomy has been scheduled multiple times at different hospitals & backed out last minute. I am fighting for my life..so..do checklists help? yes it would have in the beginning if it was followed, i think my situation shows you that some doctors do believe they are God & dont make mistakes & often when the mistakes are made you keep getting shifted around &around; or you die or until the statute expires if you wanted to take that route. I implore anyone to read about retained foreign bodies, surgical sponges/gossypibomas- almost every article is from another country they are the only ones reporting it &  guess what if its removed most of them had their lives back, the knowledge is little here in the US, most articles you find here are doctors just doing it as part of their study courses & requirements.  The intial mistake is the issue but what about the 8 years following it..millions of dollars in medical costs..there are many like me but noone knows about them - the issue is not old its very current & still happening….replace my foreign body with a nicked organ or infection or wrong site .... yes doctors make mistakes but the process after the mistakes are made is a separate & even larger issue- mistakes are meant to be rectified, for 9 years i tried to get help i just wanted it fixed & i wanted to go on to help/try to advocate where we can get the doctors/medical system & patients together & come up with something that can work.. I cant get anywhere not to mention its too difficult in my current condition now i just want to tell my story & educate people. Everyone will have surgery or know someone who will or need to go in a hospital & as much as I pray this doesnt happen or something similar….from what i am hearing its happening & happening much more often & then & only then will more eyes be open & ready to see/ change/tell a story. In the meantime i have switched focus & i will try to get my story told/media, i deserve it & my daughter deserves a mom,  i dont want to be another statistic. I commend the journalists speaking up for those who cant, i commend the advocates trying to make a change. i commend the voices/ the arguments/ disagreements that happened in the comments above because it shows some people do care. God bless!

Tom K

July 25, 2012, 2:59 a.m.

Insurer paid fee for service care tends to short circuit economic incentives to correct errors. For example, Medicare analysts often point out that the fee for service approach actually pays more to providers when they make mistakes. Good providers get paid less. Doctors do want to avoid lawsuits, but if you’re good, you get paid less.

At the same time, for the insurer the cost of tracking treatment outcomes is offset only when they can deny payment to a provider. At some point, it’s cheaper to pay for bad medicine than it is to closely monitor treatment outcomes.

I’m not sure how tweaking the system would fix this. Medicare has been struggling with it for decades.

bernadette

July 25, 2012, 9:40 a.m.

Joe, I don’t understand your point. What are you trying to say.

bernadette

July 25, 2012, 9:50 a.m.

I’m so glad to see the number of people who have experienced medical mistakes taking the time to respond in detail. In the last ten years that I was actively employed I couldn’t understand why the general public that are consumer of the health care system weren’t in an uproar over the imposion of this system. There is a model for a financially successfull practice. I was trained in it and saw it in practice until the 70’s. Nobody inside or outside the medical system wanted to hear. They had a vested interest in not seeing and brought in administration to implement the profit motivated business model. and were rewarde with huge salaries, stock options and personal gratuities.

bernadette

July 25, 2012, 10:04 a.m.

Iwould like to suggest that the nurses that have been contributing to this dialogue meet outside of this format for a discussion related to thier own experiences and ideas about resolution. I sense from reading thier comments there is a great deal of emotion involved and it appears there is at least a two track discussion, nurse who practice and non nurses who have a different perspective, not good or bad, just different. I would like to see nurses meet to discuss thier particular perspective, challenges the current system poses, and concerns about licensure.

K. Patrick McDonald

July 26, 2012, 12:56 a.m.

Jon said:

“Doctors are humans, humans are fallible, therefore doctors are fallible.”

It would be refreshing if the subject simply came down to individual fallibility. In fact it would be terrific.

But the reality in health care is that not do errant practices & procedures kill 400+ citizens a DAY, the lab coat conspiracy of not reporting the monstrous volume of misbehavior, is criminal.

The only similarity I see in my research, is the cover-ups in the hierarchy within the Catholic church.

The “system” fosters secrecy, when it has already been mandated to report it to the NPDB.

(see “America’s Dumbest Doctors” for a reality check)

Andy M

July 26, 2012, 11:55 a.m.

Hi Patrick—could you clarify your paragraph beginning “But the reality in health care…” I think there’s either a word missing or punctuation…I get the general gist but the first sentence is not clear to me.

K. Patrick McDonald

July 26, 2012, 10:36 p.m.

I apologize for the gobbledygook, Andy. Let me start over with one medic’s opinion:

The reality in health care - unfortunately - isn’t merely that errant practices & procedures kill upwards of 400 citizens each day. To make an ugly situation worse, the lab coat conspiracy of NOT reporting the monstrous volume of physician misbehavior, is criminal in itself.

The “system” fosters secrecy; dissuades simple apology, and ignores the mandate to report incompetency - and criminal acts such as fraud and totally unnecessary surgeries - to the Nat’l Practitioner Data Bank.

Less than 1/3 of the 5,700 + hospitals in this country, EVER report physician discipline, when legally required to so so.

Johannah Back

July 27, 2012, 2:39 p.m.

http://www.nytimes.com/2010/08/21/health/policy/21tubes.html?pagewanted=all


Please do all you can to prevent tubing misconnections in your facility\people under your care. Thank you-just a mom.

MARY-LOU PATEY

Aug. 3, 2012, 9:21 a.m.

my don was killed by medical errors on the part of two doctors on June 12/12 at the Cambridge memorial hospital.  To read the full story please go to http://www.justiceforjosh.com Out medical system is so corrupt it is sickening.

Commenting is not available in this section entry.
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.

Share Your Story

Your input can help ProPublica's reporting.

Have you worked in health care? Tell us what you’ve observed about patient safety.

Have you or a loved one been harmed? Tell us about it.

Join the Discussion

Join the over 1,500 members of ProPublica's Patient Harm Group to learn, share your story and connect with others.

Icon graphics courtesy of the Noun Project.

Get Updates

Stay on top of what we’re working on by subscribing to our email digest.

optional

Our Hottest Stories

  •  
  •  
  •  
  •  
  •  
  •  
  •  
  •  
  •  
  •