It has been five years since my father died. It took 3.5 years for us to learn what happened. In March my mother and I spoke publicly about this for the first time.
My family has started working with the Collaborative for Accountability and Improvement. They work to help hospitals to establish Communication and Resolution Programs (CRPs) for responding to patient harm in ways that promote healing, learning, and accountability.
This video was filmed at a training session at Lakin, Kansas. My mother and I gave the first presentation at this event.
I hope that anyone who has spent some time reading this blog comes away with an understanding that medical errors can create very deep and painful scars not just for the patient, but also for family members of the patient. In the months after my father’s death I remember spending hours and hours searching the web for any sign that other family members of medical error victims had experienced what I was experiencing: disgust that the medical system would close its eyes to the unnecessary suffering of my father, a sickening sense of betrayal by those with power over patients’s lives, and a deep frustration that my experience and expectations were deemed meaningless each time my words bounced off the fortress guarding the medical system.
I couldn’t believe that other people in this situation would just shrug their shoulders, say “Whatever!”, and go back to their lives.
In my last post I wrote about the experience of testifying before the Kansas House Committee on Judiciary about my family’s bill. In both my written and oral testimony I posed a critical question: Do patients have the right to know about unanticipated medical outcomes and harmful errors that occur in their care?
If patients do not have this right, then our bill has no basis. And if patients do not have this right, then patients need to realize this. So I asked that a new law be written that would require this sign to be displayed at every public entrance of every healthcare facility in the state: Continue reading
I came across an interesting article written in 1995 called The failure of organized health system reform—Now what?, written by George Lundberg, M.D., editor of The Journal of the American Medical Association from 1982–1999. He begins by reflecting on increasing efforts to regulate healthcare. Then he speaks to the role of professionalism in medicine. He has a perspective of what it means to be a professional that I had not heard before.
Back in 1987, the Lexington, Kentucky VA Hospital adopted a policy of disclosing errors. I found a documentary online, called The Quality Gap: Medicine’s Secret Killer, that was released in 2000. It has interviews with two key people who developed the disclosure policy, Ginny Hamm (VA attorney) and Dr. Steve Kraman (Chief of Staff).
My family’s proposed legislation for Kansas requires the disclosure of unanticipated outcomes and medical errors. It also requires hospitals to develop policies for disclosing these unanticipated outcomes and medical errors. Hospital leaders need to realize that tragic events happen in healthcare, and they should have a plan for dealing appropriately with these events.
I learned about a couple resources earlier this week that should help hospitals to develop plans for when things go wrong. Continue reading
Paul Levy is the former CEO of Beth Israel Deaconess Medical Center in Boston. He is author of the blog Not Running a Hospital.
He recently spoke at a Quality and Safety retreat sponsored by MedStar Health (a healthcare organization in the Baltimore-Washington DC area). His topic was transparency.