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.
The
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!
I’m
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.
The first commandment of the modern patient safety movement was “Thou Shalt Not Blame.”
