Video: The Telluride patient safety experience

The team at the Educate the Young patient safety blog has posted a video about the Telluride patient safety leadership training experience. It is a 12-minute documentary that explains the experience and rationale behind this camp for medical students and residents, which my mother and I had the wonderful experience of participating in last summer.

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A letter

Don’t tell me about your safety training efforts. Don’t tell me that patient safety is a priority for you. Don’t tell me how many safety organizations you belong to. Don’t tell me about your philosophies or commitments or beliefs.

My father suffered terribly in your hospital. He walked in with severe burns. Fifteen hours later, when he was finally loaded into an ambulance to be taken to a burn center, he was severely dehydrated, he was in renal failure, his heartbeat was unstable, and the base of both his lungs had collapsed. And later he died.

I didn’t need a marketing campaign. Continue reading

When things go wrong in hospitals

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

Former CEO of Beth Israel Deaconess Medical Center speaks on transparency

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.

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The slow, slow movement toward disclosure

The idea that physicians and nurses should disclose medical errors to patients is not new. In 1987, the VA hospital in Lexington, Kentucky began a policy of disclosure of medical errors and ensuring that patients receive appropriate compensation. (This was an experiement to see if disclosure and compensation would reduce costly litigation—which it did—but I would like to believe some small part of policy was motivated by simply wanting to be honest with patients and do the right thing.)

The movement toward being honest with patients about errors is slow. Very, very slow. But it is happening. I have found two essays on the topic of disclosure of medical errors written by members of a law firm that defends physicians in malpractice cases. The essays were written thirteen years apart, and the audience for each essay is physicians. It is interesting to see how the perspectives in the essays have shifted.

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Leadership and public health issues

Yesterday I was reading a book review, written by Jouni Tuomisto, in the latest issue of the journal Science. The book he was reviewing is called Toms River: A Story of Science and Salvation, by Dan Fagin. This book is about a chemical factory that was built in the town of Toms River, New Jersey in the early 1950s for the purpose of producing dyes. This dye factory (as well as another chemical factory) carelessly disposed of hazardous wastes, which contaminated the river, soil, and groundwater. Eventually the area became so contaminated that it was designated as a Superfund site. (The Superfund program was established by congress to clean up areas of hazardous wastes.)

What is the connection with disclosure of medical errors? It is in how Dr. Tuomisto describes the reasons that the contamination was not dealt with earlier. Continue reading

Where does the data come from?

If you read a few articles on the topic of medical errors, you are likely to encounter a number: 98,000, an estimate of the number of patients that die each year in the U.S. due to medical errors. In this post I am going to explain a bit about how research on the prevalence of medical errors is performed and where that often-repeated number comes from.

I was glad to find a helpful overview of medical error research in chapter 2 of Tom Baker’s book, The Medical Malpractice Myth. Using those references, I gathered the original research papers. Here is what I found. Continue reading