Home - Patient Safety

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Our health care initiatives and debates have not improved safety or affordability in the last decade, and won't in the next, because they are based on false assumptions, assumptions that often are defended as though they were unquestionable "truths." And they are defended by caregivers and the patients who have faith in them.

Below is a list of many of the pages on this site.

Home Pagepatient safety symbol - a chalk outline of patient - Patients need institutional support.

Micromanagement - ubiquitous foolishness.
Community Patient Agencies - Road map to safety.
Nequamitis - The word "Error" defeats us.
Conflict of Interest - Unacknowledged elephant in room.
Loyalty - Another reason they never will report.
White wall of silence - Solomon Asch's study.
Blacklisting Patients - They don't believe it.
Psychology of HCP - Should be prerequisite in med school.
Transparency and Dr. Hodad - Let's get real.
Cullen, Majors, and Kashyap for example.
OSMB - State medical boards are not on your side.
Ignaz Semmelweis - They always sent patients into danger.
Dr. Benjamin Rush - It always has been this way.
Pharma - Doing their own jobs
Obama Care - Would it make food better?
State Patients Boards - You mean there isn't one?
Why government cannot fix this - They have tried and tried.

Subjectivity.
Liability Limitations - Making targets out of a class of patients.
Studdert - Few legitimate grievances can get a lawyer.
Accident Pyramid or Safety Pyramid.
Written public policy
.
5% - Protecting the problem causers.
Dead Horse - Will caregivers make health care safe?
Medical Reporting - Integrity in medicine?
Medication Error Reporting - 1.3% report rate
Mandatory Reporting - Right.
Preventable Death Rate - Estimates keep going up.
Misdiagnosis - most common cause of harm.

Silence versus safety - Trends in patient safety.
Silenced - Ameliorating gag orders.
Silencing patient advocates in healthcare.
Janice M. Scully, MD - Even when the victim is a physician.
Graph.
Nurse survey - Frequency of reporting.
Nurse training - Another reason they don't report.
Mobbing and bullying - The community punishes reporting.
/ Trust us /.
Agnotology - Self-protective ignorance.
Hospital Administration - corporate ladders.
Defensive documentation - Protects HCP, not patients.
Risk management - Patients are the enemy to them.
Second opinions - Get them.
MammoSite - Why care givers do not make medicine safer.
Mammography - Why the government cannot fix medicine.
HHS Hospital Compare - Thanks for trying, but . . .
RCA or Root Cause Analysis - a litmus test for naiveté
Josie King Foundation - The problem for most patient safety initiatives.

Books - Index of the pages about books cited on this site.

Myths Believed in Medicine.
Crime in medicine - They're not errors.
Exploitation - It's not on the map.
Why a Patient becomes an Advocate.
Apologies in Medicine - sorry works .000004% of the time

OSMB Investigators.
Disciplinary Action Chart for 2001.
Disciplinary Action Codes.
National Practitioner Data Bank.

SOAP - Guide for what physicians are supposed to record.
Management Issues - Enforced institutional ignorance.
Sexual Abuse - No structures protect patients from miscreants in medicine.
Freedom of Speech for Patients - Patients should be as protected as physicians.
Defamation - Speech can be expensive.
Patient Safety - Medical mistakes and frivolous suits.
Electronic Medical Records - And we worried about Google?

Motivation to make a site like this.

Oversight - Doctors want oversight of other people.

Corruption -

Examples

If you want to understand a system, look at examples of how it handles its worst moments.
Dr. Allan Zarkin - Doctors are humans. They do bad things.
Dr. Liana Gedz - A victim testifies before Congress.
Dr. James Burt - The system removes normal inhibitors.
Dr.Arthur Richard Schramm - No one checks even huge red flags.
Dr. Graeme Reeves - Victims stonewalled by health authorities and laughed at by police.
Dr. Vikas Kashyap - Same old, same old. 
Dr. Michael Swango - Yes, murderers are protected in medicine.
Donald Harvey - Sometimes they are orderlies or nurses aides.
Kristen Gilbert - nurse serial killerKristen Gilbert -  "If my patient dies, can I get off work early?" 350 murders possible. (See book at right.)
Orville Lynn Majors - A lack of moderation can get noticed.
Charles Cullen, RN - They say the system lacks a way to spread the word.
Dr. Gary Malakoff -  Having "MD" after your name is a get-out-off-jail-free card.
Dr. John Story - Raped and molested patients for 25 years.
Nechemya Weberman - Victims afraid to speak.
Dr. David C Arndt - Surprised anyone would be upset.
Richard W. Gibson - Stealing patient's identity.
Genene Jones, LVN  - What does a serial killer look like?
Dr. Harold Shipman - What to learn from the world's most prolific serial killer.
Catherine Wood and Gwen Graham - Nurses who played a "Murder Game."
Dr. Michael E. Sachs - An example of how helpless patients are to find out about their healthcare.
Dr. Federico Castro-Moure - Another glimmer of how much power and protection doctors are used to.
Dr. Shafik Ahmad - 13 complaints with no medical board response until after police arrest.
Richard Neale - 28 year trail of misery.
.... Dr. Errol Wai-Ping - Even when it only is incompetence it takes a group to get anyone to pay attention.
Kimberly Clark Saenz - Nurse who put bleach in syringes.
Dr. Spyro Panos - Unfriendly practices with cooperation.
Dr. Antiq Durrani - Medicine protects problem operators.
Christopher Duntsch - privately said he was a stone cold killer.

Other examples on which you could search:

Beverley Allitt - Britain. At least 4 murders.
Richard Angelo - Long Island, New York, at least 10 murders
Robert Diaz - Riverside, California, 12 murders
Terri Rachals - Albany, Georgia. 23-year old intensive care nurse. 6 counts of murder. 
Brian Rosenfeld - Florida, 23 possible murders    
Jane Toppan - Massachusetts, at least 31 murders
Efren Saldivar - California, at least 6 murders
Dr. Jayant Patel - The Butcher from Bundaberg
Sigmund Freud - Recent research shows he put personal interest in front of the well being of patients.
Lucian Leape - He authored the original IOM study that finally forced the medical community to admit it kills a lot of patients unnecessarily, but he still is a physician and still drinks their snake oil.
Bryan Sexton - The world’s leading expert on patient safety culture and therefore an example of the problem.

"Medicine hates its victims."
If that doesn't ring true in the center of your heart your knowledge of patient safety is only theoretical. If you flat out don't believe it, you probably work in medicine.

Injured patients have written to me applauding my saying that.

Hippocratic Oath

Complaint Process Overview
Medical Complaints Homepage - How and to whom to complain in medicine (it isn't easy or effective).
List of State Medical Boards
Complaint form
To whom to complain?

Links

Medical Information Release

Medical Billing
Universal Insurance - Concerns about government involvement in managing healthcare.
Canadian Health Care - a Canadian says it is not as wonderful as some suggest.

The Saint Theory of Medicine
Home Page Addendum

Food for Thought

End of life planning and senior living planning in general

Miscellaneous

JCAHO - The Joint Commission on the Accreditation of Healthcare Organizations
Metal on Metal Hip Replacements
The Back Surgeon - Fiction sometimes is the best way to make problems understandable.
Author
 - A few lines about the author
Chalk Outline - "Save the Patients" symbol
Open letter to Daniel Shore
Journal - Abandoned diary of the path leading me to an operation that was unnecessary.
facebookization - Promotion versus exploration.
Odds - We have to have a sense of humor, don't we?

The inscription on the CMS Hubert Humphrey Building at Harvard Medical School says, “The moral test of government is how it treats people in the dawn of life, the children, in the twilight of life, the aged, and in the shadows of life, the sick, the needy, and the handicapped.”

This is a job only part of which can be done by political entities. The patient community, as a group, must get the information and resources to protect themselves. That information is not collected anywhere by anyone at present. It is not merely a matter of asking for records. They must be created. Although an agency authorized by the government and populated with injured patients with the single agenda of advocating for patients, probably is the first thing that must be created, perhaps something like a state patients board, in order to make any of the rest of this possible.

Links

Click links to see other sites, many of which were set up by victims of adverse events in medicine. Many of the most important and most progressive institutions in the world were set up in the same way, as responses to specific and horrible abuses. The Magna Charta was a social revolution against the specific abuses of a specific tyrant. The Magna Charta was the insistence that steps be taken to end such abuses. The bulk of the Declaration of Independence is a recounting of the abuses of George III and a declaration of the institutions that would be established to correct those abuses. Many of the web sites set up by injured patients are no different. The people who injure them continue to injure patients with an indifference encapsulated in hubris and denial. They do not listen to their victims. They stymie, silence and dispense with them, frequently branding them as cranks. They can do this with clear consciences because their processes by default persuade the caregivers themselves of their own innocense. And so the story told by patients tends to be the same time after time, with no one in medicine ever hearing it, as can be seen in the sites set up by some of their victims.

Intentional Harm

Is this even on the radar of anyone in medicine? Has it ever been mentioned in any important bill in Congress? Victims of it cannot create web sites making people aware of it because when they do they get sued.

That's too bad because crime in medicine could be the most important issue in medicine. On this site, the point of discussing crime in medicine is to shed light on patient safety problems. The conflicts of interest of providers is the fundamental problem. Criminal law is the first step for addressing that, but the systems, culture, mindsets and habits protect even crime in medicine. As long as that is the case, there is no hope for progress on the biggest issues. If I were to relate in detail an instance of sex abuse and violence in a hospital and how depraved the caregivers were and how they got away with it, it would be to shed light. The perpetrators of that instance are church-goers with children. They are respected members of their community (who in medicine isn't?), but have passions that destroy people's lives - something they can get away with because of where they work. What they do afterwards to silence their victims is the most despicable of all. How this works is important to know. We hear the statistics on how much assault, rape and homicide there is in medicine. What we don't hear is why virtually no one is reported, let alone indicted for those crimes, why the criminals are allowed to keep committing crimes, and why we so rarely hear from the victims. If you can shed light on that, you have a duty to. When you are a victim, it is because no previous victim shed that light to protect you. For all of the errors and neglects causing the several hundred thousand unnecessary deaths each year, and many times more unnecessary injuries, the beginning of the solution is getting a handle on the intentional ones.

*        *        *

In 1968 CIA analyst Sam Adams was sent to Saigon. There he discovered that intentionally incorrect information was being generated. He did not make that public. Since he did not stop it, doctored information continued to be sent to the president. Going public could have ruined his career. It even could have landed him in jail, so he didn't. Years later he said that if he had gone public, the Vietnam Memorial would be only half as big as it is because the war would have stopped sooner and half of the people named on that monument would not have been killed. He never got over his remorse for that.

When you know a truth like that, you have a duty to tell it for the common good, even when you will suffer for doing it. It's too bad there is almost no one in medicine interested enough in the well being of patients to do that. They won't even let patients tell other patients what they have learned. The number of lives Sam Adams could have saved was about 25,000. In medicine they kill that many people unnecessarily every month. The people in medicine who keep their abuses quiet, and who silence the patients who try to reveal them, are far worse than Sam Adams..

hand hygiene
solutions

medical errors
one number - reporting needs to be encouraged
Petitions - Please don't ask me to look at them anymore
Citizen oversight of Medicine - doctors cannot police doctors

Mass murder and psychotropic drugs - medicine doesn't watch itself enough and never can be expected to. They are the wrong people for the job.

XXXXXX hospitals - historical source for culture of silence, (had to  delete it because of backlash)
Death by Caduceus -

The World Health Organization’s definition of health:
a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.