A newspaper in my mother’s town ran an article announcing that the emergency room received a Women’s Choice Award and was “among America’s best hospitals for emergency room care”. I was curious about the award, so I looked into this. I am sharing what I learned because it is an example of how publicly available hospital performance datasets can be used to mislead and misinform healthcare consumers. Continue reading
Let me review what has been said about policies in Kansas for disclosure of harmful medical errors and unanticipated medical outcomes: (1) My family has been told by representatives of the hospital which treated my father that state law prohibits them from talking to us about my father’s care, because this would violate the peer review statutes. (2) During this conference call, the concern about disclosure violating the peer review statues was again voiced. (3) In testimony before Kansas House Committee on Judiciary last Monday, it was said that hospitals and physicians are already doing disclosure, so a state law is not needed.
Clearly, something does not line up. I suspect that no one knows how many hospitals in Kansas have disclosure policies, because very few hospitals in Kansas are accredited by the Joint Commission (which has required disclosure since 2001). And I suspect that no one has a sense of the content of the policies that do exist. And that lack of knowledge is a problem that can be addressed with a research study. Continue reading
There is a petition on change.org that is similar to my family’s efforts. This petition asks Kansas hospitals to investigate patient safety incidents. It was posted by Tim Graber of Moundridge, KS. He is asking that Kansas hospitals embrace “The Seven Pillars” approach to investigating and learning from patient safety incidents. The author of this approach is Timothy McDonald, MD, JD, Chief Safety and Risk Officer at the University of Illinois Medical Center. You can read more about the Seven Pillars process in this PDF. Continue reading
I spent all day looking through the previous Kansas apology bills, notes on those bills, and committee meeting notes that mention which organizations supported or opposed the bills. I compiled the history of the bills and a list of the organizations that provided testimony here.
My purpose was to figure out what organizations are likely to have an opinion on my family’s bill. Our bill provides more protection for apologies than any of the previous bills, but it also requires the disclosure of unanticipated outcomes and medical errors. Continue reading
I realize that disclosure is not easy, and that there are both personal and institutional barriers to disclosure. But I am quite certain that somewhere out there in the state of Kansas, some healthcare professionals (and maybe even a couple healthcare organizations) have made the decision to do the right thing and practice disclosure. I don’t mean the scripted, guarded, I-will-tell-you-something-but-not-the-real-story-and-now-I-want-you-to-go-away type of “disclosure”, but authentic human-to-human disclosure.
And for those people, I want to share a note of thanks: Continue reading
I have been looking on the web for evidence that professional healthcare societies in Kansas acknowledge that medical errors are a serious problem. I did find one statement on the website of the Kansas Healthcare Collaborative (KHC, an organization formed by the Kansas Hospital Association and the Kansas Medical Society). On the For Consumers page is the statement Medical errors cause tens of thousands of deaths each year. But you can help. Get more involved with your health care. (They provide link to the Agency for Healthcare Research and Quality, but it is broken. It should go here.)
It is good to see the epidemic of medical errors has, in this small way, been publicly acknowledged by a professional healthcare society in Kansas. And I completely agree that patients should be doing whatever they can to help reduce errors. But ultimately, the responsibility for reducing errors lies with healthcare workers and healthcare organizations. And the leaders of those healthcare organizations. Continue reading