By Michael Millenson

Anyone who cares about patient safety has to be grateful to Dennis Quaid
for the way he and his wife Kimberly reacted to the near-death from a
medication error of their twin baby girls. Using his celebrity and his
contacts as an award-winning actor, Quaid launched a crusade to stop
similar errors from ever happening again. He has appeared on 60 minutes , testified before Congress and, Sunday, came to HIMSS to tell his story once again.

At HIMSS, Quaid was amusing (“I am not a doctor [and] I have never
played a doctor on television or in the movies”) and moving, as he
detailed how two massive heparin overdoses turned his newborn twins’
blood to the consistency of water and left them bleeding inside and
out. He was also generous and humble, repeatedly thanking the HIMSS
membership for the work they did in developing the technology that can
prevent inevitable human error from causing harm.

Quaid made clear he was not denigrating “overworked and
underappreciated caregivers.” He pointedly declined to make
Cedars-Sinai Medical Center in Los Angeles the “bad guy.” (He was not
so kind to drug companies, blaming similar labels and colors of the
10-unit and 10,000-unit jars of heparin for the mistaken overdose.)
Instead, Quaid showed a few short video clips from quality crusader Dr.
Charles Denham  that underlined the need for systemic health care improvements.

Yet if anything, Quaid was too generous to providers. To call for
“leadership” to solve the medication error problem, and to focus mainly
on the drug companies, misses the painful point that providers have
morally failed their patients. After all, there’s been plenty of
leadership. The problem is that for reasons both financial and
cultural, most hospitals and physicians have refused to follow the
leaders — and they have suffered no reputational penalty for doing so.
As I wrote in 2003 in a Health Affairs article entitled, “The Silence”:

Suppose
that an airline’s managers and pilots repeatedly resisted installing
collision-avoidance systems despite solid evidence of their worth.
Suppose, too, that they complained that the radar was not reimbursed
adequately, required inconvenient retraining, provided no competitive
advantage in attracting passengers at a timewhen airline profits were
low, and (sotto voce) was an insult to pilot judgment. No one
would…absolve individual pilots and managers of responsibility for
that disaster simply because they never intended for passengers to be
harmed.

LDS
Hospital in Salt Lake City showed back in the early 1990s with articles
in the medical literature that it could cut drug errors to less than
the theoretical minimum. The death of Libby Zion, daughter of New York Times reporter
Sidney Zion, prompted an inquiry that in 1986 recommended all New York
City hospitals have computer systems to prevent drug-drug interactions
leading to similar deaths. But in 1998, when the HIMSS Leadership
Survey asked hospital executives which of ten clinical challenges were
driving increased reliance on information technology, the two that tied
for dead last were “creating comparative outcomes data” (1%) and
“reducing errors” (1%).

This history was not mentioned by HIMSS — indeed, has undoubtedly been
forgotten by HIMSS — as it announced a $10,000 donation to the Quaid
Foundation 

I bring up the past not to point fingers but to point forward. In the
real world, financial incentives, transparency and a firm demand by
patients that professionals live up to their own moral code are what
motivate sustained improvement. Passionate speeches don’t do it.
Splashy stories in the news media don’t do it. Pleas by celebrities
don’t do it. Scholarly articles don’t do it. Systemic change is hard
work.

I applaud Dennis Quaid for resisting bitterness and scapegoating.
However, just as actors study their roles in a movie, Quaid owes it to
himself and those patients he wishes to help to study up on the role of
a genuinely effective patient advocate. The Quaid Foundation says its
mission is “raising the standard of patient care.”  Bravo! But being a
widely heard voice is not the same as being an effective one. If Quaid
wants to prevent other families from suffering the terrifying
experience he and his wife went through with their baby girls 17 months
ago, he must learn the lessons not only of his own past, but the the
hospital industry’s, as well.