Robert Wachter is widely regarded as a leading figure in the modern patient safety movement. Together with Dr. Robert Goldman, he coined the term "hospitalist" in an 1996 essay in The New England Journal of Medicine. His most recent book, Understanding Patient Safety, (McGraw-Hill, 2008) examines the factors that have contributed to what is often described as "an epidemic" facing American hospitals. His posts appear semi-regularly on THCB and on his own blog "Wachter’s World."
The Entertainment Blogosphere was atwitter this week with the story
of actor Dennis Quaid’s twin
newborns, who reportedly received a
1000-fold heparin overdose at Cedars-Sinai Medical Center in La La
Land. Cedars’ Chief Medical Officer Michael Langberg may win this
year’s Oscar for fastest public apology – having learned the lesson
from the 2003 Duke transplant error, where the hospital stonewalled for a week or so, adding chum to the media feeding frenzy.
error came during heparin line flushes, when a 10,000 units/ml solution
of heparin was mistakenly substituted for the intended 10 units/ml
solution. Although the cases required pharmacologic reversal of the
anticoagulant effect, thankfully there were no bleeding complications.
These cases come on the heels of last week’s report
out of Dallas that the state-supported UT-Southwestern kept an “A-list”
of potential donors and assorted bigwigs. Apparently, when these folks
come to the hospital or clinic, they may get a personal greeting, a
preferential parking spot, perhaps even an escort to their appointment.
My friends at Health Care Renewal, who chronicle and condemn healthcare’s corporate influences, were shocked. Shocked!
not. Every hospital I know keeps some sort of a VIP list, a tripwire to
alert the organization of the arrival of a dignitary or billionaire.
Even when there isn’t a formal list, you can be sure that a single call
to the CEO’s office is more than enough to lift the velvet rope. That’s
a simple fact of life, and to me not worthy of a big fuss.
of course, they’re getting better care than Joe and Jane Average. But
are they? Believe it or not, I really doubt it. In fact, there is a
sizable medical literature describing the “VIP Syndrome,”
a disease you don’t want to have. In a fascinating article, the Israeli
docs who cared for Prime Minister Ariel Sharon after his devastating
brain bleed put it this way:
VIP syndrome is characterized either by decisions to minimize the
number of diagnostic and therapeutic procedures or, alternately, to
work-up every minor abnormality to appear very thorough. Another aspect
of this syndrome is fragmented care, i.e., care by multiple specialists
each focusing only on their area of expertise.
And, I’d hasten to add, it often isn’t any
specialist, it is the organization’s most famous, Nobel Prize-winning
superspecialist – you know, the one who often needs a map (“you walk
past the cafeteria, make a left at the dialysis unit, and you’re
there!”) to direct him to the ward. Get a gaggle of these folks
involved in someone’s care, and you’ve got one hell of a mess on your
How can the VIP Syndrome be prevented? In 1993, the editor of the journal Chest suggested that:
best decisions in reversing the ravages of the VIP syndrome are to take
measures to ensure the privacy of the VIP, to place limits on the
visitors, and to explain that the care will be identical to that given
to all other patients with the same condition. There is nothing
biologically different about a pope or a president, and there is no
need to alter one’s thinking in caring for them.
is all very nice, but one still wonders whether VIPs and their families
get safer, more attentive care. My favorite story about this pertains
to Dr. Don Berwick, probably the world’s most revered quality and
safety leader. As I described in Understanding Patient Safety, Berwick writes poignantly
of his wife Ann’s harrowing string of hospitalizations for an obscure,
progressive neurological illness. Berwick took her to some of America’s
greatest teaching hospitals, where, as the wife of a famous physician
and patient safety advocateshe was as VIP as you can be.
And yet, wrote Berwick:
The errors were not rare; they were the norm. During one admission, the neurologist told us in the morning,
“By no means should you be getting anticholinergic agents [a medication that can cause neurological and muscle changes],” and a medication with profound anticholinergic side effects was given that afternoon. The attending neurologist in another admission told us by phone that a crucial and potentially toxic drug should be started immediately. He said, “Time is of the essence.” That was on Thursday morning at 10:00 A.M. The first dose was given 60 hours later—Saturday night at 10:00 P.M. Nothing I could do, nothing I did, nothing I could think of made any difference. It nearly drove me mad. Colace [a stool softener] was discontinued by a physician’s order on Day 1, and was nonetheless brought by the nurse every single evening throughout a 14-day admission. Ann was supposed to receive five intravenous doses of a very toxic chemotherapy agent, but dose #3 was labeled as “dose #2.” For half a day, no record could be found that dose #2 had ever been given, even though I had watched it drip in myself. I tell you from my personal observation, no day passed—not one—without a medication error.”
There is no evidence that Dennis Quaid’s kids were harmed because they hail from a VIP bloodline, but it wouldn’t surprise me if it was a causative factor. Everybody just tries a bit too hard, and in doing so, they throw off their natural rhythm. In any case, when we get a VIP admission at UCSF and the residents ask me how they should approach the case, I always say the same thing: let’s work our tails off to be sure that nobody hurts them.
Whether you’re a VIP or not, have a safe and happy Thanksgiving.