OP-ED

The Patient Safety Movement Turns Ten

On December 1, 1999, the Institute of Medicine released a report entitled To Err is Human: Building a Safer Health System. Although its authors hoped to spark a national movement, they had little cause for optimism. After all, early efforts by advocates like Berwick and Leape and organizations like the National Patient Safety Foundation had barely moved the needle of public and professional attention.

The IOM Report succeeded beyond its framers’ wildest dreams, and the movement they spawned turns ten today. Please indulge me while I spend a nostalgic moment recalling the remarkable spin that launched the patient safety field. I’ll then segue to a summary of my assessment of what we’ve accomplished over the past decade (I outline this more fully in an article in this week’s web version of Health Affairs, which I hope you’ll take a look at).

In Internal Bleeding, after describing the history of the IOM (founded in 1970 as the National Academy of Science’s think tank for healthcare issues) and the fact that the venerable organization was not exactly known for its eye-popping PR, Kaveh Shojania and I wrote:

So one could not help but be taken aback by the screaming headlines that leapt off the book jacket of the [IOM Report]. One part Constitution Avenue to three parts Madison Avenue, its tone instantly caught the attention of the general populace and the media. Just consider the breathless prose of the book jacket, more like the trailer for a Hollywood blockbuster than the synopsis of an academic report:

Experts estimate that as many as 98,000 people die in any given year from medical errors that occur in hospitals. That’s more than die from motor vehicle accidents, breast cancer, or AIDS—three causes that receive far more public attention…. This volume reveals the often-startling truth of medical error and the disparity between the incidence of error and public perception of it…

As if that wasn’t enough pizazz, the authors converted the staggeringly large but potentially bloodless “44,000-98,000 deaths per year” figure into the now-famous “Jumbo Jet Units” – making the point that the number of deaths from medical mistakes was the equivalent of a large plane crashing every day.

Although some have critiqued the “crash-a-day” spin as hyperbolic, I continue to believe it was masterful. Something was necessary to shake us out of our collective inattention, and it took the Jumbo Jet analogy to do it. (And just consider what our response would be if, in fact, a commercial airliner crashed for “just” two or three days in a row!) The IOM Report received saturation media coverage for several days, after which more than 50% of Americans surveyed were familiar with the epidemic of medical errors. In one bold stroke, medical mistakes joined airline and food safety (and, two years later, terrorism) as enduring sources of angst in the American zeitgeist.

While there are many metrics of the IOM Report’s impact, my favorite is this: even today, one can say “The IOM Report” and most folks will understand the reference to To Err is Human. This, despite the fact that the IOM has published 526 reports since To Err is Human. Want more: a Google search on “Institute of Medicine Report” pulls up the IOM’s website as the first hit; To Err is the second.

That’s all well and good, but what have we actually accomplished? In today’s Health Affairs article, I present my view of the progress we’ve made in the patient safety field’s first decade. I give us an overall grade of B-, a slight increase from the C+ I awarded 5 years ago in a similar Health Affairs paper.

In writing today’s article, I was struck by the emergence of state reporting systems, centered around the National Quality Forum’s list of “never events,” as the key maneuver that got safety reporting off the ground, and the increased safety activity within hospitals (many of which now have fairly effective patient safety enterprises) and national organizations (such as the NQF and AHRQ). On the other hand, it is remarkable how little progress we’ve made in IT (particularly when you contrast it with the breathtaking progress we’ve made in IT in virtually every other part of our personal and professional lives), and how we’re just beginning to grapple with balancing “no blame” and accountability. And, as I feared, regulators and accreditors are facing increasing challenges, as the low-hanging fruit (such as abolishing high-risk abbreviations) has been picked, leaving them struggling to improve performance in highly complex, nuanced areas like safety culture, medication reconciliation, and addressing problems caused by disruptive caregivers.

Many people will look at the past 10 years and wonder whether we’ve accomplished much of anything. I sympathize with this concern, one that’s partly driven by our maddeningly limited ability to measure progress in safety. Yet as I wander around my own medical center, signs of progress are unmistakable. Our safety enterprise is much more vigorous than it was five years ago (it was nonexistent 10 years ago). Despite some major IT snafus, we are using an electronic health record, and it is a far better way of communicating information than via snippets of chicken scratch penned on dead trees. During a weekly two-hour meeting, we analyze serious errors and review progress in fixing the unsafe conditions we uncover. Our residents and students are (mostly enthusiastically) participating in new safety and quality curricula. We are measuring safety outcomes such as healthcare-associated infections and reporting these results regularly at the highest levels of the organization. All good stuff.

Yes, there is much more for us to do. Patients everywhere are still harmed by preventable infections, falls, communication glitches, wrong-site surgery, medication mix-ups, and more.

But that’s for tomorrow. Today, let’s also take a moment to celebrate all the good work over the past ten years. In fact, had you asked me on December 1, 1999 how much progress would be possible in the next decade, my guess would have markedly underestimated what we actually have accomplished. As I visit hospitals and healthcare systems around the country, I have been struck by the passion and energy doctors, nurses, pharmacists, and administrators have put into preventing patient harm – driven as much by their moral compass as by the increasingly robust business case for safety.

So, even as we vow to redouble our efforts in the second decade of the patient safety movement (and we must), we should take some pride in the work of the first, work that has unquestionably saved many thousands of lives.

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56 replies »

  1. I agree Lisa. I found this quote in another blog that aptly describes the JCHAO…
    “Lately, the JC has devolved into something akin to an aging toll booth operator who lazily takes a token from every motorist who wishes to pass, with nary a glance to see if the vehicle they’re driving is actually road worthy.” this is from the HealthCare PSI Blog.
    Ain’t it the truth.

  2. Kathy, whether they’re accredited by JCAHO or not is irrelevant. Having JCAHO accrediation is like saying they’re listed in the phonebook.

  3. JCAHO doesn’t accredit all hospitals. I also contacted them and the small Maine hospital my father was infected in and died as a result was not JCAHO acredited. So, obviously they were no help to me. The same hospital is now associated with a major medical center here in Maine. I am fully confident they will now be accredited and nothing about any past HAIs or errors will matter one tiny bit. Those failures involved 3 deadly infections in one single month in a 25 bed hospital. And those are only the ones I know of. My father was one of them.

  4. I wrote to JCAHO at least 4 times. I got the same letter back each time. “The hospital’s response, if any, is confidential.” Except the 4th letter said the file is closed. I monitored JCAHO’s website over an approximate 18 month period at least, they never set foot in this facility as a result of my many well-documented violations to their standards. There are many, many similar stories. Here’s an example of a sentinal event at a JCAHO facility, the child died while JCAHO was on-site doing their inspection. They didn’t do anything about it (IE: suspend accrediation status pending investigation). http://www.lewisblackman.net Healthy child slowly bled to death over a 4 day period. Mom kept asking for a doctor, she recognized the symptoms of shock from what she learned in high school first aid. Nurses were too busy polishing doorknobs and hanging decorations in anticipation of their upcoming JCAHO inspection to bother with a child in crisis. This was back when they used to schedule their inspections. By the way this was a healthy child admitted for an elective procedure. If that’s not negligent homicide, I don’t know what is. “A boy scout could have done better” said the local paper. Indeed.

  5. I too have contacted JACHO and asked if I could be of assistance.I’m not sure what they are doing but I found them as nothing more than a sounding Board. Taking on personnel experiences and Archiving them.
    They sent their standard letter that the received a reply from the Hospital and that the contents cannot be revealed for my review and /or rebuttal. Actually, Jacho acted in the same manner as the Hospital and the Department of Health. They would not discuss or allow review of the subject matter.
    Bev, When I have spoken about arrogance. WE know that some are arrogant but it is the Hospital and the industries cultural Arrogance that is most Frustrating. I do not see Lisa as being arrogant because I have empathy for her experiences. I know some of those experiences and know them to be true.
    On the other hand Health Care Workers do not want to focus on the unpleasantness of Staph Infections and Medical error. I don’t know why they fail to recognize the threat? Could it be they are paid the same regardless of outcome? Could it be that re-admissions benefit the Hospital and Death benefits the undertakers union? How narcissistic can a person become in this field of study and still claim to care about Patient Safety?
    The most important question is; what do they have to fear to included community members to set patient safety policy? Answer: Health Care cannot Control the outcomes due to career status.

  6. Bev MD, I didn’t blow you off, I’ve responded to all your comments with the reality that is being a patient safety advocate. It’s not arrogant or patronizing, it’s just the facts. You should be alarmed, as a citizen of this country and no doubt a patient yourself one day, that our efforts over the years aren’t bearing results. Instead of wishing us well in our endeavors, why don’t you help us by contacting your legislators and demand mandatory public reporting of medical errors (this includes infections), demand patients be able to access their records without restrictions, demand patients have access to an advocate of their choosing 24/7, demand the CDC and DHHS clean up the industry by regularly investigating complaints, regularly inspecting hc facilities and reporting on same, and in general doing their job, demand national standards for physician and HCW licensing, and demand the FBI investigate JCAHO. There’s a good start we could use the help.
    Or, enjoy your golden retirement years in blissful ignorance and we wish for you that you don’t find yourself in our shoes one day. It’s guaranteed you will if the above mentioned items don’t start happening.

  7. Bev M.D.:
    We’re not arrogant. We’re angry. We’re angry because we’ve lost our loved ones to a system rife with dysfunction and incompetence. We’ve been denied answers. We’ve been denied justice. We’ve been fighting against arrogance for years. So if you sense cynicism, it’s nothing personal. We just loved and our loved ones lost.
    And by the way, while your dispensing advice to us on how we can change the system, what are you doing to change the system now that you are retired? Most of us are not retired. And we spend countless hours and more energy than Con Ed trying to change the system. And without a 401K.

  8. Lisa;
    My conclusion from our discussion:
    “All patient advocates are arrogant because one of them obviously already has all the answers, patronized me when I tried to be helpful, blew me off when I tried to make suggestions, and generally made it clear she has been at this far longer than I and knew much more than I did.”
    Spoken tongue in cheek, of course; but sounds like something one of you might say about docs, huh? Just sayin’. I wish you well in your endeavors; I need comment no more.

  9. Bev MD, we have supported including the pt/family in RCA for years, original credit for this goes to Helen Haskell in South Carolina. When such a suggestion is made to the industry you get a deer-in-the-headlight response…and then they start telling us about our “perspective” (it’s different) and we (pt/family) don’t understand how “complicated” healthcare is. Been there, done that, still doing it.
    JCAHO…I appreciate your suggestions but honey, please, don’t get me started on the Joint Omission, their hands are covered in blood and the FBI needs to start throwing JCAHO executives past and present in prison.
    #2 is also a good suggestion, I think we have all at one point or another spoken at medical schools. Trying to get the cirriculum changed is an ongoing battle as well. Been there, done that, still doing it.
    Thanks

  10. My involvment in and education re patient safety ended when I retired in 2003, so I get the increasing impression you all know more than I do. However, here’s a couple ideas, building on your comments and the quotes from Drs. Berwick and Cassel:
    1. Use your joint clout to try to get the Joint Commission to require patient/family input in the process of root cause analysis, which as you know is the formal process where a hospital investigates a sentinel event or near-miss. Not that you should sit in on the whole process; the legal aspects would scare them away. But that, as well as gathering input from the providers and staff members involved in the event, the RCA team is required to interview the patient or family member for their input and perception of the event.
    2. Try to pressure the Association of American Medical Colleges (http://www.aamc.org/) to include in their undergraduate curricula (e.g. at the medical student level) formal education on systems thinking, teamwork on how to reduce errors, root cause analysis process, etc. This could start with aksing to give a guest lecture on a sentinel event and how it affected you as the patient or family member. I can promise you the medical students would be riveted – I still remember every patient who came to our lectures in physical diagnosis, etc. and told us how their disease had affected them. They are at least thinking about this on the graduate level (http://journals.lww.com/academicmedicine/pages/default.aspx), but I think that’s too late in their training.
    Again, you all may be way ahead of me, but you have the power of a critical mass and passion.

  11. There’s an advocate on the east coast who was told by a hospital CEO “We don’t want to see your faces.” Because we’re the faces of their failures.
    Another advocate encountered the CEO of her subject hospital at an event recently. The last time she saw this CEO was at the settlement conference years earlier regarding the harm to her son. She told me it took everything she had in her to approach this CEO and say hello. The CEO had no idea who she was. The most devastating event in advocate’s life happened in this facility, changed her life, and sparked a crusade that’s going on a decade. It was just another day at work, and totally forgettable, to the CEO. Since that time advocate has tried to engage the CEO in working jointly on patient safety, even tried to negotiate a joint presentation at an upcoming event the advocate had, hospital said thanks but no thanks. Advocate used the media to put public pressure on facility, as a result of the Modern Healthcare article, it was the first time in 10 years the hospital had anything to say other than “no comment.” It’s quite a lot of shenanigans advocate has had to go through, and is still going through, to try and partner with hospital leadership. Her name is Sue Sheridan.
    Memorial Hermann in here in Houston continues to ignore me, the executive leadership all know who I am. Dr. Bev, The Hospitalist article made the rounds with the patient safety advocates, many of us wrote letters to the editor and I believe they were published online or will be in a future edition. I’ll check on that.

  12. Dr Bev,
    I agree with both of the doctors quoted. Hospital Leadership and Medical Educators just don’t “get it”. Maybe they need to recruit real life victims and/or families of victims to educate these people. They and some other professionals have no idea how their errors/neglect impact patients and their families. It is so simple for people who sit in nice plush offices or professors who no longer interact with (or even touch) patients to just slide over the cause and impact of adverse results. Those results I am referring to are death or long term disability.
    Somebody needs to bust the bubble these people live in.

  13. Here’s an interesting quote from a 10 year followup interview with 2 of the IOM’s original committee members issuing the report 10 years ago:
    “Q: In retrospect, what was missed in the report?
    Dr. Berwick: If we missed any boat in our analysis, the idea of “no blame” is not meant to relieve everyone of responsibility for medical errors, but to relocate responsibility for safety in the offices and work of leaders of healthcare institutions. The finger points to the executive suite. There’s more and more evidence that safety does not improve without the clear commitment of leaders.
    Dr. Cassel: When we think about how we train doctors, which I spend a lot of time doing, they just aren’t trained to think of root-cause analysis or how to work in teams to reduce errors. That needs to change. ABIM’s new pathway for hospitalists, which will be rolled out in another year or so (see “A-Plus Achievement,” p. 1), treats questions of how … to identify patient-safety issues as core knowledge.”
    I think both of these answers are right – except Dr. Cassel’s efforts need to be refocused on medical schools rather than just hospitalists. I have heard from someone in the industry that medical schools just are not getting it in terms of this training being a necessary part of their curriculum.

  14. Don’t ask me Lisa. I’m Conflicted. The absence of common sense and due diligence seems to be contrary to the mission of this Profession. If your civil and respectful the entire profession blows your concerns off as some fiction novel. While if you take the approach of getting into their Faces and spouting the Obvious,the Profession seems to treat you as some lunatic. Either way they are not going to listen.
    Our Federal Government bribes these professionals to achieve realistic goals and they use grants to woe investors.
    Strangely enough, these professionals are not in the least, concerned about their own welfare. Or even if they are the vehicle that spreads Hospital Infections to the patients.
    I guess this is considered Defensive Medicine. If no one knows than the reality is, no one can be held accountable.If someone were to weaponize staph infections that targeted Health Care Workers. Then they would be pushing for immediate change.
    We all know there are solid evidence based research and proven track records to support ADI precautions. I don’t know why it is so difficult for the industry to accept the obvious? I guess they have spent to much time sitting on their brains.Suffocation does kill brain cells!

  15. While it may feel good to focus on certain areas of “progress” in patient safety, anything that does not transmit down to immediate improvement in the way patients are treated and ensures their safety is little more than window dressing. I can’t think of any business in this country that is given such an outrageous pass on abuses, negligence and incompetence the way healthcare is. Having the foxes rate the fox with preformance score cards and the like is just another way of doing anything but the right thing.
    These are literally life and death matters for patients and nothing short of immediate action is appropriate.
    There is no substitute for real accountability.

  16. Gary, I’m not sure why you even gave that advice (don’t be angry) the time of day. It’s high time this angry mob got out their pitchforks, damn your studies and data. Bev MD, you should watch this webcast and listen to the journalists speak about how difficult-to-impossible getting data on patient safety matters is: http://mindmedia.vo.llnwd.net/o21/kaiser/091117/f.htm
    Also, one of CNN’s 5 tips on not falling victim to medical errors is to “be impolite” http://www.cnn.com/2009/HEALTH/11/11/hospital.mistakes/
    And finally, if you went through the same trials and tribulations with your 88 year old mother, you would have found quick results once you started throwing some flames of anger. Why are our standards so low in healthcare? Why is that? Everywhere else in society we value human life…as long as it’s not receiving medical treatment, that is. Why is that?

  17. Hi Bev,
    Thank you for your thoughts on this Matter. Still,The Grief process is unpredictable and displays a variety of emotions. I can honestly say that I have on numerous occasions made concerted efforts in a pleasant tone and manner and it has fallen on death Ears.I have for the last two years forwarded new Data to the State Legislature and the Tennessee Department of Health on a weekly bases.Simply,to keep it from being out of mind and out of sight.
    Doctors seldom actively listen to Patients and it is the arrogance of the profession that places patients at greater risk.It is the Culture much more than the person that can jeopardize a patients Health.I also wonder why some Long Term Doctors,who have the GOD Syndrome are not required to have a psychological review to see if they are fit for duty.
    On the subject of Credibility. Its Obvious that the profession relies overwhelmingly on Data. Something that can appear objective can be subjective by the provider of the study. If a Pharmaceutical wanted to promote a new product and slants its findings to back its product. How credible is that report. Their have also been findings that are contrary to other articles on the same subject. How credible is that data?
    “I am simply pointing out that the minute the anger and flame-throwing surfaces, you completely negate your credibility with anyone in a hospital or doctor’s office, and probably in your congressman’s office too.”
    How do you explain the Political Parties that has been Catering to the Far Right?
    What I’m getting to is the fact that data can easily by manipulated to support any argument. The Problem from a non Medical student point of view.I do not have access to the proprietary studies of this profession.
    Being Civil and failing to express ones self in a stern and unyielding manner . Often times fails to obtain results. For example: My sister has a pinched nerve in the back of the neck. She would follow the suggestions of the Doctor,go to therapy etc; without relief. I told her to be firm and not to take no for an answer and get a referral to a surgeon. She got her referral!
    Arrogance is a wall that limits communication,forms judgments founded or unfounded, and is a precursor to a closed mind set. It is that mindset that makes the Concerns of Infections such a Hard sell from the patients prospective. They (the Patients)are the ones bearing the burdens of medical Errors and Infections. By doing nothing makes ignoring it blissful as they have No idea where it came from or how it happened.
    We can’t simply wait for the profession to get its house in order. After all they have been chasing the profit lines for to long.We will change the system one patient at a time and make all aware of the unforeseen cost of Hospitalization.

  18. I can assure Dr Bev that my fellow advocates and I went to our legislators on both the State and Federal levels, prepared, informed and angry *justifiably so). The anger for the loss of our loved ones because of negligence and inadequate care, fired our passion to actually do something about it. None of us will ever get our loved ones back. But, we can use our anger, our grief and our knowledge to fire up a prevention storm in our states and country and to help others to avoid the same horrible fate.
    Generalities won’t work, I agree, but when we have the facts that are available about medical errors and preventable infections, a little anger-fired passion never hurts. In fact, a substantial number of the representatives I have spoken with had some pretty impressive horror stories of their own that made them angry.

  19. Hi Gary;
    I am happy to be the lightning rod for physicians since I am retired and worked in a laboratory anyway. So you see, I was on the other end of the MRSA issue. I completely understand your anger and have experienced it myself on other issues (medical records, lack of communication, lack of thoroughness) on behalf of my 88 year old mother and other relatives completely ill-served by our health care “system”. I am simply pointing out that the minute the anger and flame-throwing surfaces, you completely negate your credibility with anyone in a hospital or doctor’s office, and probably in your congressman’s office too. This may be unfair, but it is reality. If you want to have an impact, cite data and studies and say “this is unacceptable”, rather than “all doctors (substitute whatever other provider you like) are arrogant”, etc. etc.
    It’s not what you are saying, it’s how you are saying it which will deny you the impact you desire and deserve.

  20. Dear BEV Md.
    I agree with Kathy on the fact that this Conversation would be unnecessary if Hospitals did their part.I also Agree with Lisa that these infections are not intentional and we have some good professionals doing the best they can.
    Its been over two years since my mother had died from contributing factors from MRSA and the absence of ADI. I have gotten over my anger a couple of months ago but I have not given up for my passion to spread the news of the hidden Dangers of Hospitals,Out Patient,Long term and nursing home Care.
    Did you know that arrogance kills patients and ignorance is Bliss? My father who lost his wife was told M(e)RSA was nothing to be concerned with; siting the medical journal. Actually, arguing with a 81 year old man, (who just loss his wife from complications with MRSA such as sepsis) as if he is a stupid, ignorant, commoner. Such arrogance and no- it- all attitudes is what Kills Patients.Of Course, to Claim Ignorance is bliss and forgoes any accountability.
    Food and Water Watch tracks several studies on MRSA and antibiotic resistance in animals. As you know most studies are proprietary and are not publicly shared.For the same reasons that the medical profession chooses to hide their study outcomes.
    In the presence of ever increasing evidence based studies on this subject. It is most alarming when arrogance and apathy seems to trump common sense life saving practices.If the Medical Professions fail to act in the protection of their patients from preventable infections and Medical Error. Than please don’t expect me to back off anytime soon.
    These stats that you refer to are severely flawed and out dated.I for one can tell you that my mothers bout with MRSA was Not counted in Tennessee. As I followed Up with the State Department of Health and Vital Statistics.
    It good that you question data ,but remember its not the Holy Grail.I can not send you any data about anti biotic resistance in animals with out you being suspect of my motives. So I would suggest you do the research yourself and report back on your findings.
    We must see the entire picture and not box ourselves into a repeating thought process that fails to recognize a grander theme.

  21. Bev MD
    My father was in the hospital the entire 12 day incubation period of his MRSA. He arrived on his first admission with clear lungs and normal WBCs, no fever and no sign of MRSA pneumonia. He was discharged after 12 days and then he was home 1.5 days when he collapsed with his infection. There is absolutely no doubt he was infected while hospitalized…absolutely none. Yet you’d like to say “we dont’ know the facts”. I know the facts and the doctors who treated him for his MRSA know the facts. They told me and my family that he contracted MRSA in the hospital.
    Please don’t assume that we advocates and activists are liars or dummies….we know our facts and we get them straight.
    And about anger….I couldn’t possibly be any more angry about my fathers infection. And you would be too if it happened to your father, mother, child, sibling, etc.
    Data…what a joke. Many hospitals fudge data or they don’t release any. MRSA data is the best kept secret in the USA.
    I used my anger (not data, because there isn’t any available to the public) to get a law passed in the State of Maine to screen all high risk patients. The hospitals have fought it tooth and nail, but I fought back. With this screening, hospitals cannot say that “the patient brought the infection in with them, or they were likely infected when they came in, or some visitor infected them, or any of the other lame statements that many victims or their survivors have heard repeatedly. If one is MRSA negative on admission and becomes positive while hospitalized..after 48 hours in hospital….it is hospital acquired. Seems pretty obvious to me and the CDC agrees. If they are positive, then it makes the hospital aware that the patient is at a huge risk for active MRSA infection and they must take the appropriate steps to prevent it. They must also stop the spread from colonized or infected patients by isolating, using contact precautions and considering decolonization. So, not knowing a patients MRSA status is no longer an “excuse” for hospitals…at least in Maine.
    I have listened to docs just like you say the same things over and over defending their facilities saying they are doing the best of everything possible… And like Lisa, I know none of these infections are intentional, BUT
    They should have been spending their time working on improved prevention instead of fighting it. That way their MRSA rates would be dropping and there would be no need for this conversation.

  22. Gary, I do not contest your comments, but do you have references supporting your contention that giving antibiotics to feed animals has resulted in the proliferation of CA-MRSA? It would seem logical that is so, but I have learned that what seems logical in medicine is not always true. Like it seemed logical that stenting every clogged coronary artery would improve mortality, but it doesn’t, except for certain subgroups of patients.
    Remember, data is king, not anger.

  23. Yes ,I’m aware of Community Acquired MRSA and why do you think that is ? Could it be the abuse of Anti-biotics in agriculture? 23 Million Tons of antibiotics are used each year on Healthy Animals because of overcrowded and unsanitary Conditions.Eight(8) times that is used in Humans in a Given Year.In just 30 months of a cows life before slaughter.They have been injected with more antibiotics than we receive in our lifetime.
    The AMA is very aware of these practices that use antibiotics to accelerated growth of our Chicken, Cows and pork to name a few. Food and Water Watch have released reports that document antibiotic resistances in healthy animals to promote growth. You are what you eat is so true and even though you are the most Health Conscious. The very organizations that are suppose to protect your health are deceiving us regarding what is safe.
    Considering all that takes place in Hospitals and even Agriculture. It would seem that Best Practices and Antibiotic Use regardless of industry should be a No Brain er. However, it is often ignored in the interests of profits.
    So as long as CA-MRSA and HA-MRSA are largely being Ignored. Please for give me for spreading news of Anti biotic resistance and how to identify and protect yourselves from it.
    In the future, I hope Health Care will recognize High Risk Patients and test them for MRSA. Using ADI as a means to address the issue. The VA of all Hospitals are doing a Terrific Job in this Area. The Lab can identify the difference between the two. However, Hospitals do a terrific job covering up Hospital Acquired. So not to risk needless exposure to lawsuites.

  24. Um, I’m not going to get involved in the MRSA fight above, but I assume those involved are aware that there is a strain of MRSA which is community-acquired and that the incidence of this strain is increasing faster than HA-MRSA?
    http://www.cdc.gov/ncidod/dhqp/ar_mrsa_ca_clinicians.html
    Obviously we have no way of knowing which strain was involved in the cases cited above, but it is simplistic to categorically state that all MRSA cases which first manifest within a hospital are by definition hospital-acquired. A visitor carrying CA-MRSA, for instance, could give it to the patient.
    Not being defensive, just trying to keep this discussion factual.

  25. Does anybody know if Rhode Island Hospital uses their checklists? For those who might not know, RIH was recently fined $150k for 5 wrong site surgeries. (not sure why it took 5 events to get action, but anyway…). Patient safety advocates endorse the use of checklists, with respect to wrong site surgeries checklists are 100% effective at preventing a wrong site surgery. So, I’m wondering, does anybody know if RIH used checklists? Because if they did we need to know why the use of checklists failed.

  26. How do I know (that charts in my hospitals are mostly accurate)? Because I know at least a large part of what’s going on with the patient, and what is documented by whom and when.
    I’m sorry but this isn’t an answer. The answer is you do not know.
    Again, most hospital staff is not interested in harming patients. If that is what you think, I am not sure whether you are in the right field. I never said anybody INTENDED to hurt patients, but it’s happening nonetheless. With great frequency, and as other posters have mentioned here, often times it’s PREVENTABLE. Rbar I don’t believe you have spent much time as a patient in a hospital.

  27. How do I know (that charts in my hospitals are mostly accurate)? Because I know at least a large part of what’s going on with the patient, and what is documented by whom and when. Again, most hospital staff is not interested in harming patients. If that is what you think, I am not sure whether you are in the right field.
    Re. physicians protecting each other, it probably still happens … but probably not as often as you suggest. I have seen academic physicians (not “experts from the gutter” as you suggest, although boundaries are blurred here) testifying harsh and unfairly against other physicians. I have seen internal peer review with physicians secondguessing colleagues without mercy. And I have heard many physicians (and patients reporting physicians) speaking in a derogatory fashion about other physicians or aspects of the care they received from other physicians. In other words, there are physician diagreeing in pretty much any kind of scenario, for various motives (money, narcicissm, personal feuds and antipathies). The great cover up you witness and/or perceive is becoming the exception (and that’s a good thing). Or maybe there is tremendous regional variance I am unaware of, but this is something you might want to acknowledge yourself.

  28. “In fact, at least in the various hospitals I worked at (from community to tertiary care), charts are usually very accurate.”
    How do you know? What qualifies you to make that statement?
    “…medical staff of hospitals or even the entire personel are conspiracies against the patient’s health…” Rbar, you’re giving the industry way too much credit. A conspiracy would require teamwork, collaboration, they’d all have to be working together to pull off a conspiracy against us. They’re not that organized.
    You know when I finally saw my husband’s medical records, and started (trying to) read them, I was shocked. Errors, ommissions, even outright lies. My sister, who had been a nurse for over 13 years at that time, was flummoxed as well. I finally asked her, is this what they teach you in nursing school? Be vague and non-specific? Omit important details? Is this what they teach you do to? She said no, quite the opposite, they taught her if it isn’t in the chart, then it didn’t happen. Such as, elevating the head of an intubated, ventilated patient. Something drastic changed in health care since her days in nursing school, I think lawyers took over.
    Rbar, you’re mixing scenarios. A expert from the gutter paid to testify at trial is not the same physician or scientist who’s reviewing medical records for scientific studies.
    And yes, there is a lot of cronyism going on in health care, doctors do protect each other. You keep going to the court room, I’m not in the court room.

  29. Robert,
    I don’t blame anybody for things that my father did to himself. He could have led a healthier life. I do however blame the hospital for an infection that he caught while hospitalized there. I blame the hospital for not addressing 2 other MRSA deaths just prior to my fathers infection. I blame the hospital for inadequate infection control and not even abiding by the soft and lax CDC recommendations for MRSA control after an outbreak.
    YOU BET I DO BLAME THE HOSPITAL. They caused his infection and it could have been prevented.
    Just out of curiosity…who would you blame…my father??? I dont’ think so. He went into the hospital for a minor ankle fracture and had NO invasive procedures done. Then he ended up dead 3 months later after a great deal of suffering…not from the ankle fracture, but from a hospital acquired infection.
    I a totally justified in blaming his hospital and so are the other 19,000 people who die each year from hospital acquired MRSA infections.

  30. Hospital Acquired Staph Infection deaths exceed that of HIV/AIDS in the United States. MRSA accounts for 65% of all Staph Infections. So why is it treated like the Common Cold?
    Some 2 million people are disabled by staph infections,losing limbs,jobs and Quality of Life. Why should We Care? Answer: Its PREVENTABLE!!
    Who Knows, the next roll of the Ambulance might be your turn to experience the preventable. After all infectious Disease has no Boundaries.I hope none of you have to experience it.

  31. Your selective BINGO quote suggests that physicians do not second guess their fellow physicians. That’s not true as you pointed out yourself.
    With regards to the medical records, I am a little bit surprised about your statements, and I did not make the point you tink I made. The study I quoted/pasted does not at all suggest that charts are factually inaccurate, but that complex medical care is very often hard to consistently rate as appropriate or inappropriate.
    In fact, at least in the various hospitals I worked at (from community to tertiary care), charts are usually very accurate. How would falsifying medical documentation work anyway? If someone does not document anything about an event or encounter, it will usually backfire (failure to diagnose or to intervene are common causes for malpratice suits) as it creates the appearances of idleness/negligence for the person failing to document. If someone documents falsehoods (which BTW only “makes sense” for the writer if a serious mistake is known or suspected, but not prospectively, while the mistake is done), there is a high chance of being contradicted by other staff/witnesses. If you talking about changing the chart in retrospect, that may happen rarely and is often discovered, bringing the changer into serious trouble with a potential jury.
    IMHO, the IoM study as well as some safety advocates create paranoia that the medical staff of hospitals or even the entire personel are conspiracies against the patient’s health (or at least against any attempt to clarify mistakes and improve outcomes). This might very well be the case sometimes and you may have witnessed this (and this of course should not be tolerated and I think is getting more rare every year), but that is not the rule and not the assumption you should make when you enter a hospital.

  32. What Part of Preventable do you not understand;Robert.Its not the Blame game. However, it is the ability to recognize a problem and address that Problem.Apparently, you have not experienced staph infections of family and friends close up.So it is described as blaming without changing the Direction of the Spread of Infectious Disease.
    The Facts are these people want to bring forth the needed changes to protect others from experiencing needless loss of life. By the way that includes you!
    Across the country, We have had spotty programs in the reduction of Preventable Disease. Some have made tremendous strides and others have done little to address Hospital Acquired Staph Infections. Those who have ignored best practices have the highest incidence of death and disability.
    The Health industry has for the most part snub the HA-MRSA and other staph Infections as Part of Doing Business.However those who have taken on ADI guidelines have made impressive gains. In the absence of sound practices by these institutions. It is every citizens duty to spread the Knowledge of Hospital Acquired Infections and protect themselves from potentially deadly outcomes.
    I hope that you supply your patients with hand sanitizer to limit the spread of MRSA.

  33. Rbar, with regard to your other question, physicians testifying unfairly against other physicians. I don’t know how to answer that question directly other than to say based on my knowledge of the legal system, anybody with a checkbook can find any so-called expert right out of the gutter and get them to say, under oath, whatever the writer of the check wants them to say. I’m sure there are physicians who give expert testimony against other physicians, what’s your point? It’s not up to you or me to decide whether it’s fair or not, that’s what judges and juries are for.
    The insurance company that sued my husband got one of those out-of-the-gutter “expert” doctors to testify. He never laid eyes on my husband, was never involved in his case, and testified over the phone from 300 miles away. What’s your point, Rbar?

  34. Rbar, I did read your entire post, I am not going to read it again now but you mentioned charts not being reliable sources of information more than once and I don’t know why you would call this selective reading or whatever else you’re diagnosing me with. Now you’re getting to the root of the problem, enough said, medical records are not reliable or accurate sources of information. It was a good point and whether or not you wanted to make it, I’m glad you did.

  35. Most of the posts here seem to be about finding someone to blame when something bad happens. When I see outpatients with no previous contact with the medical system who present with life-threatening MRSA infections, whom should I blame? Thanks for the help!

  36. Lisa,
    Based on your previous posts, I would have expected you to do better than selective reading (selective perception and interpretation of facts is actually a very real source for error/misdiagnosis, one of the things you are dedicated fighing). Did you read at least to the end of that very paragraph? Moreover, have you ever heard of physicians unfairly testifying against physicians?

  37. When I recount the 21 days in the Hospital, I too can remember how drastically my mothers chances of survival would have been. If Active surveillance, detection and Isolation Practices were part of hospital ER and Admission Practices. No one else can feel the pain, loss,frustration, and anger.
    Vancomycin was administered knowingly being aware of Boarder Line Kidney Failure. Within Hours her chances of Survival were cut short while the Vancomycin shut down her Kidneys. Ending in multi-Organ Failure. All we could do is unknowingly watch Her slowly Died. The Doctors were such cowards that they darted in and out of the room in the we hours of the morning. Trying to avoid the family.
    Its really amazing how many people in Health Care are unaware of MRSA killing people. Quite a few! Of course, the medical journals always keep the stated incidences as low as possible. Speaking from experience,I can attest to the extremes that are taken to cover up the extent of infections.
    Most nurses are stunned when you say my mother died from MRSA. The next question was “Did she have anything else wrong.” If you say yes;the nurses feel comfortable and relieved by my answer.I wanted to say Duh! Still,We don’t know how virulent the strains are because their is no uniformity and reporting is voluntary and fractured.
    Most Hospital staff knowingly expect to be colonized and never get tested. After my mother died we all got tested 30%of the family was colonized and one had it in the lymph nodes. Of the 30%,20% worked in Hospitals.
    In my view,Such behaviors are counter to do no harm and is willfully negligent.

  38. Hospital acquired infections are medical error or neglect. The method of prevention is available and proven and yet it is ignored. Active detection and Isolation is the method of prevention. Several activists like me are working to get that into our states hospitals.
    It enrages me when I hear doctors blaming patients for their own infections. My father was disabled and had ongoing health problems when he was admitted to his hospital for a minor fracture of his ankle last fall. Until his injury, he lived at home, independently with my mother. He drove his own car and did his own errands. He was visiting in my home,70 miles from his own…a week before he fell and hurt his ankle.
    He rehabilitated for 12 days for his fracture and was discharged home with a walker. He collapsed with MRSA pneumonia that he contracted in the hospital less than 2 days after he was discharged. He spent 20 more days in the hospital and 9 weeks in a nursing home before he died as a skeletal, sad and depressed old man. MRSA did this to him. MRSA is preventable in hospitals when the right steps are taken. MRSA took the lives of 2 other elderly patients within one month prior to my father. Both of them were candidates for joint replacement, but they both died from infected new implanted joints.
    Blaming the patient and saying they would have died soon of something else anyway is a pathetic excuse for poor infection control while they are hospitalized. It was nobody’s fault but the hospital’s that my father became infected with MRSA…..NOBODY’s. I hear it all too often…”well, they would have died of something else soon anyway”. I believe my disabled father would have had another good year or more at home with my mother if his hospital had not killed him with a preventable infection. Instead we will spend our first Christmas without him this year.

  39. “Reviewers may be reluctant to second-guess the care of fellow clinicians, and many errors may not be documented in the medical record or identifiable by chart review.”
    B-I-N-G-O

  40. Tom,
    Just saying something is not an argument, is, IMHO …. uhmmmh … not an argument. One cannot claim that scores of healthy people are killed in the hospital when life expectancy is very limited and causation is unclear:
    (from Rodney A. Hayward et al, JAMA. 2001;286:415-420)
    (…) this is the first study to our knowledge to question reviewers about the likelihood of death in the absence of the error, to examine the patients’ underlying short-term prognosis, and to consider the effect of variability in reviewers’ ratings on these estimates.
    As predicted on theoretical grounds,many deaths reportedly due to medical errors occur at the end of life or in critically ill patients in whom death was the most likely outcome, either during that hospitalization or in the coming months, regardless of the care received. However, this was not the only—or even the largest—source of potential overestimation. Previously, most have framed ratings of preventable deaths as a phenomenon in which a small but palpable number of deaths have clear errors that are being reliably rated as causing death. Our results suggest that this view is incorrect—that if many reviewers evaluate charts for preventable deaths, in most cases some reviewers will strongly believe that death could have been avoided by different care; however, most of the “errors” identified in implicit chart review appear to represent outlier opinions in cases in which the median reviewer believed either that an error did not occur or that it had little or no effect on the outcome.
    These results do not suggest that medical errors are unimportant. (…)
    Although our study helps clarify some issues regarding medical errors, whether physician reviewers can accurately make such assessments from the medical record remains uncertain. Our study uses the same basic methods as previous studies, structured implicit review, and suggests that if this is accepted as a valid way of addressing this issue, statistics taken from previous studies1 are probably overestimated. We agree with investigators who note that we must be very cautious in making causal assertions from retrospective reviews. However, we are not confident that currently available instruments to adjust for severity of illness are adequate to assess the overall impact of medical errors on outcomes (although severity adjustment and rigorous methods may help produce estimates for specific processes of care). Given the complexity of hospital care, in the foreseeable future implicit review may be the best source of estimating the overall impact of errors.
    Implicit review could underestimate medical errors. Reviewers may be reluctant to second-guess the care of fellow clinicians, and many errors may not be documented in the medical record or identifiable by chart review. Our study also may overestimate the consequences of medical errors. First, although we instructed our reviewers to not second-guess reasonable clinical judgments, hindsight bias is part of human nature and empirical evidence exists that this occurs in physician implicit review. Unlike the clinicians who cared for these patients, our chart reviewers had the advantage of knowing the final diagnoses and outcomes. Chart reviewers may consciously or subconsciously allow this privileged knowledge to result in second-guessing reasonable decisions and inflate the true merits of alternative choices and decisions. Another possible bias for reviewers’ estimates is that physicians tend to overestimate how long sick patients will live, often dramatically so. Although the previous studies were conducted on physicians who were providing care to the patients, if our chart reviewers, who did not know the patients, similarly overestimated the probability of short-term survival, this would result in further overestimation of the impact of optimal care on truly preventable deaths.
    The statistics on preventable deaths have captured the public’s attention and, to the extent that the current patient safety initiative fosters an efficient and effective approach to error reduction, it has great promise to improve the health care system and produce positive outcomes. However, as demonstrated by this study, the statistics that brought much of this attention do not support the tenet that hospitals are unsafe for patients, as some interpretations of these statistics have suggested. Furthermore, while some well-publicized cases have been patients with long life expectancies, if our results can be generalized to other hospitals, they suggest that most of the cases that make up the dramatic statistics occur in substantially different situations. While deaths due to medical errors are still extremely important even when patients have very short life expectancies, the correct understanding of these errors may differ substantially from how they have been publicly portrayed to date.
    Our study also suggests that finding patterns of care that result in truly preventable deaths may prove more difficult than previously believed. It is sometimes implied that the egregious errors that make the media headlines (like unintentionally amputating the wrong leg) are representative of the types of errors found in implicit review studies. If that were true, the interrater reliability of implicit review should be much greater than 0.25 for 2 reviewers. In all general medical and surgical chart review studies to date, reviewers have had a difficult time agreeing on whether an error caused an adverse event or even on whether something was an error at all. Reviewer agreement is usually even worse when specific processes of care are evaluated (as opposed to overall care) and attempts at improving the true reliability of implicit review by discussion between reviewers have been unsuccessful.13 Under such circumstances, finding patterns can prove difficult, and trying to fix problems in complex settings using hindsight and anecdotes can lead to changes that may increase, not decrease, errors. Finally, these results have direct implications for using risk-adjusted hospital mortality rates to assess hospital quality. Past research suggests that the correlation between ratings of “preventable deaths” and actual prevention of deaths would have to be very high for disease-specific hospital mortality rates to be an accurate measure of hospital quality.
    In conclusion, we found that our physician reviewers often reported medical errors and frequently reported deaths as being preventable by better care (at a rate similar to previous studies). However, 3 caveats were identified that have implications for preventable deaths: (1) the probability that the error actually caused the death was often considered to be low; (2) reviewer assessment of errors had poor reliability and was usually skewed; and (3) the underlying short-term prognosis of the person who died was often judged to be very limited. Medical errors are undoubtedly common and contribute to many adverse outcomes. However, if our results can be generalized to other hospitals, the statistics on deaths due to medical errors do not accurately reflect the view of most physician chart reviewers. Our results suggest that these statistics are probably unreliable and have substantially different implications than has been implied in the media and others. Most importantly, this study demonstrates the limitations of this means of identifying errors and highlights that caution is warranted when establishing causal relationships between errors and patient outcomes.

  41. In traveling around the country to various Healthcare Conferences I do see a great number of grass roots small initiatives put on by caring nurses and a few visionary doc’s.A good example of this bottom up change is a group of Infection Contol Nurses in New Mexico who banded together and cut their states MRSA rates in half in one year. When I asked them what their biggest challenge was they replied it was getting their CEO’s and CFO’s to let them change the status quo. I would agree with your B- grade for the front line of Healthcare however I would rate the nation’s Healthcare Leaders lower than Don Berwick did. Leadership continues to promote a lot of talk, very little action, and miniscule funding when it comes to patient safety initiatives. Hopefully they will see the light soon as in the next 20 years this group will be retiring and become primary users of the system they have created. I pray they have a better experience/outcome than I did.

  42. The pharma companies are the one’s getting all the money. No kidding we have a lot of work to do outside hospitals as well. Rbar you’re correct we should focus on preventable errors. Preventable medical errors are still way too high and I agree with Dr. Don Berwick’s grade of C- http://blogs.chron.com/deadbymistake/2009/11/berwick_gives_patient_safety_p_1.html
    “You want to address the mistakes that matter and that can be prevented with a realistic effort.” Indeed, Rbar, indeed. What do you consider realistic? Is giving a patient or their advocate a copy of their record realistic? I think so. Is wiping an invalid patient’s bottom realistic? I think so. Responding to an alarm on broken equipment? Not giving penicillin to a patient with a known allergy?
    Until the industry gets it through their thick heads that patients are their customers, progress will continue to be sluggish. I want to share with you an email I circulated last night regarding an industry event I attended:
    Today I was at another one of those seminar’s. The topic was the “Patient Perspective.” Let me share with you a couple of highlights. When making introductions with my tablemates, when I said I was a pt safety advocate a woman next to said the flames on my book cover reminded her of a fireman that came to a hospital she worked at in California and taught everybody about patient safety. Oh, he was quite good, and sure enough when the Loma Linda earthquake hit the staff knew how to mobilize because what the fireman taught them about patient safety.
    She was serious.
    I explained that I don’t teach what to do in the event of a natural disaster, that when I said patient safety I was referring to medical errors, that patients are harmed or killed as a result of their medical care and I keep telling our story as an example of how things can go wrong and how easy it is to prevent.
    She didn’t know what to say to that.
    How is it possible that there are still people in the health care industry that don’t know what patient safety or medical errors are? Then again, this WAS in the Texas Medical Center, Land of the Dinosaurs.
    At another point during the day I met a man who worked for the State Health Department. He saw our poster and said “Oh, you’re one of those people who think doctors screw everything up, right?”
    I said “Actually, no, we had some pretty good doctors, it’s a system problem moreso than an individual worker problem.”
    “Well, patients have unrealistic expectations.”
    Yes, really! He really said that!!
    Back to my tablemate. After a bit more discussion, she asked “What part of the country were you in?”. Without missing a wink, I pointed out the window and said “Right across the street at Memorial Hermann.”
    I wish you guys could have seen her physical reaction.

  43. I think I read somewhere, and I don’t remember where, that the leading cause of error is actually misdiagnosis. If that is true, then I’m not sure what is needed to fix the problem other than more time with patients, better histories (rbar mentioned that for hospitals too) and a general slow down of the assembly line.
    Talking about meds, is it just me or the TV media is flooded with pharma ads lately? There is even a commercial for bariatric surgery running here all the time. Are these effective? Do patients come in asking for the stuff they see on TV? Those are very expensive drugs….

  44. I think Lisa and rbar are both right. However, the issues in hospitals are receiving all the attention, while the outpatient/drs offices issues are not. To illustrate rbar’s overmedication example, my 88 yr old mother recently recovered from 5 months of unrecognized drug-induced delirium caused by polypharmacy for back pain, including Flexeril. (They thought it was Alzheimer’s). The back pain had been worked up stem to stern also. I recently learned from an expert in this area that Flexeril is one of the worst medications for producing delirium in the elderly. I confiscated all of her medications, and she moved to a retirement home with an inhouse physician. When she complained of her back pain to this physician yesterday, the doc put her on – Flexeril.
    Two problems here – many general practice docs do not have a large enough knowledge base on these issues, and our lousy health IT system prevented the new doc from access to her medical records which would have elucidated all the previous workup/treatment for her back pain AND the drug induced delirium. So we have potential waste in repeating all the back pain studies, and potential patient harm from re-prescribing a drug harmful to her.
    I am preventing all this because I am a physician and know how to work the system – but what about those millions who don’t? There go your tax dollars and many, many lives. Lisa, you have even more work to do outside hospitals.

  45. Dr. rbar writes:
    > The US is probably doing OK if not better
    So you & Dr. Watcher agree we deserve the B- then. Great. I do hope you abandon the “they were going to die anyway” argument though. It is no argument at all.
    t

  46. Lisa,
    I know that many mistakes are made in hospitals, some of which are egregious and definitely preventable … others are misjudgments or minor oversights and turn out to be mistakes only with hindsight knowledge. Many of the supposedly deadly mistakes in the IOM study were in critically ill and may not at all changed the likely outcome. Please read the article I mentioned, if needed, I can quote the source tomorrow.
    Making mistakes is part of human nature. Obviously, you want to minimize mistakes in health care as much as you want to minimize mistakes in street traffic or in the factory with heavy machinery. You want to address the mistakes that matter and that can be prevented with a realistic effort. For instance, one could reduce the rate of mistakes made in the ER by requiring specialists to be present (or to come in) every time an ER doc needs specialist advice and not allowing them to phone in advice … but is this a realistic effort?
    Again, I have seen what’s going on in 2 other industrialized and 1 developing countries. The US is probably doing OK if not better in terms of safety (we should be given the ressources we are putting into the system).
    Instead of trying to eliminate every technical error and misjudgment in the complex care of sick patients (of course we shoul try to learn from those, individually and in terms of process/system performance), let’s rather focus on real and preventable culprits such as overmedication in the US – many elderly patients are on multiple superfluous drugs, are overly sedated and break their hips from preventable falls. I actually think that most safety advocates look after things that matter. But the IOM numbers give a wrong idea of what the real problems are.

  47. Rbar, Dr. Berwick from IHI estimates 15 million injuries to patients per year. You’re skeptical because you just can’t believe it. People who know better DO avoid going to hospitals and when they have to go they make sure they have an advocate with them. People ARE harmed or killed in hospitals for no good reason, no reason at all other than carelessness. See http://www.deadbymistake.com. Truth is we really don’t know what the real number is because data is not available to study or measure. The industry keeps a real tight lid on their dirty laundry.

  48. I am deeply skeptical about these figures, and other, smarter than I people share this thought (for instance the JAMA artcile: “preventability is in the eye of the beholder” that I linked to from previous posts). If previously healthy people are just killed or massacred in US hospitals for no good reason, more people would avoid going there.
    I have no doubt that we (i.e. everyone in healthcare) could do a better job, esp. with regards to improving procedures (such as the time outs, improved history taking and documentation that I note on a daily basis). Dr. Wachter and fellow pt safety advocates certainly deserves great credit …. but I think the above figures are nonsensical and illogical.
    The biggest problems in US medicine, IMHO, are access problems and (at times hazardous and always costly) overutilization for those who do have access; safety problems/aviodable errors are in the 2nd tier (that’s still high, though) and probably better than in other industrialized countries offering complex technical care.

  49. I find this incompatible. One hand we complain about patients ready to sue for all silly reasons and then on other hand hospital not mustering enough courage to implement hygeine and safety checklist and consequently face high preventable morbidity. How do the two co-exist?

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