Patient Safety - Reality Check

Donald Harvey
"The Angel of Death"

He appeared to enjoy confessing as much as murdering

This is yet another story that is brushed off by people in medicine as being so bizarre and unusual that it is irrelevant,  rather than being recognized as an accurate picture of how systems in medicine work at their worst moments.

Medicine is arranged as though all healthcare workers are well-meaning and competent. This enables miscreants in medicine to prey on patients with impunity, like Swango, Cullen, Burt, Jones, and others. Smaller sins and abuses occur everyday without anyone finding out.

There is a crime rate in medicine. Donald Harvey, Angel of DeathFor anyone to notice requires events so bizarre that even this system cannot keep them hidden. But if you wanted to prey on people, you'd be hard pressed to find a safer place in which to do it than medicine. The best people in the world have have bad days, and have self-interests, that make it so that at times they cannot be trusted and need to be policed. But no one does that in medicine.

As large as were the abuses of Donald Harvey, for word to get out about it required luck, an inquisitive reporter and a nurse with initiative, as covered in the detailed and interesting book about it shown above. The luck was both that an autopsy happened to be performed on a victim (something done in only about 5% of patient deaths) and the coroner happened to notice the smell of cyanide before it decayed, which is does in about a day. That lead to the suspicion that Donald Harvey, an orderly in the hospital, might have poisoned the patient, a patient who had not been expected to survive, so it was thought to be a possible mercy killing.

The inquisitive reporter was Pat Minarcin, a television news reporter who, on the air, happened to ask the police if they had investigated whether Harvey might have killed any other patients. The police said no, which is to be expected. Police generally expend little to no energy when the problems are in medicine.

The nurse with initiative was one who had heard that broadcast and telephoned Minarcin anonymously to tell him that he was on the right track. It is rare and lucky that one nurse took that initiative. Many nurses knew there was a problem, but it is a rare nurse who does something about such problems.

If that reporter had not asked that question, and if that nurse had not heard him ask it, one of the most prolific serial killers in history might still be killing in medicine today. No one was keeping track of the rates of patient deaths on various wards. No one was listening to nurses who were trying to report it. Harvey had been murdering patients for a couple of decades without interference.

Many things may have changed at Drake Hospital as a result of its being the home to so many murders, but culture is nearly immutable. Nurses still almost never report anything anywhere in medicine (see nurse survey). No one listens when they do. In this case when nurses tried to report it, as usual they went only to their supervisors and, when rebuffed, went nowhere else. In what other field do employees not call the police when one of their colleagues is believed to be murdering people? Did any of the nurses even think to report it to the state medical board?

The commonalities with similar cases
in medicine are numerous

The anonymous nurse told Minarcin, the reporter, that something was going on in that hospital and the supervisors wouldn't do anything about it. She wouldn't give her name for fear of repercussions, but she did agree to contact the reporter again. When she did, she had a second nurse with her on the line. The nurses said that several times they had reported Harvey to their nursing supervisor. At first they were ignored. After a while (perhaps after the supervisor's having had time to check with people higher up) their supervisor ordered to them keep quiet.

The two nurses gave Minarcin three more names of patients whose deaths they thought suspicious, but when asked for proof, said they were unable to do more.  Although they did agree to speak again. When they contacted him again there were five of them on the line. They refused to identify themselves because of the repercussions this could have for their careers (one hears this continually from people in medicine, but hears a continual denial of such pressures from people not in their position). However, he was able to persuade them to meet with him.

The five healthcare workers told him that the day after Harvey's arrest the chief administrator of Drake Hospital, Jan Taylor, had called a meeting of the staff who worked on the ward where Harvey worked. Mr. Taylor said that the hospital had conducted an internal investigation and found no indication that anyone else had been killed (which is what hospitals always seem to find when investigating their abuses). He also said that the police had done a thorough investigation and confirmed the findings of the internal investigation (based on what? People in medicine are notorious for not cooperating with police investigations. Police often simply defer to the hospital's investigation). He ordered them not to speak to reporters and asked them to avoid discussing it among themselves.

That is normal policy in medicine. Don't even discuss it with colleagues. It is how institutional memory is destroyed.

In fact, the only investigation that should have been necessary to raise questions was to investigate the rate of patient deaths on the wards. When Harvey arrived the death rate tripled on his ward.

If patient safety was their goal
they already would track such information

When Minarcin met with them, the five healthcare workers gave him names of more patients who died suspiciously and told him about how they were rebuffed by their supervisors when they tried to report this. Minarcin's list of victims now numbered 33 and had names and dates. Since Drake was a public hospital, Minarcin was able to get records he would not have been able to get from a private hospital.

Jan Taylor got wind of what he was doing, denounced him as a sensationalist and claimed he was just trying to get TV ratings. Minarcin was afraid that if he broke the story, the hospital would sue him and the TV station. There are no liability limitations protecting the people who are sued by healthcare workers (unequal protection, isn't that?).

Liability limitations protect them, not us

Minarcin spoke to Harvey's lawyer, William Whalen, who didn't believe what he was told. Whalen went to Harvey to warn him that this story that might appear in the press. Harvey was more intelligent and more articulate and more likeable than most of Whalen's clients. Harvey worked in healthcare, after all. It never had occurred to Whalen to ask Harvey if he was responsible for any other patient deaths. When he asked that question now, Harvey said, "Yes." When asked how many people he had murdered, Harvey said he only could estimate.

What if Harvey had lied and said, "No?" Would he have returned to the safe harbor of medicine where they are so good at protecting their own?

The culture that allows this
is not isolated in time or place

Soon Whalen learned that this wasn't confined to just one hospital and that it had been going on for twenty years. If hospitals did more autopsies, think how much sooner they might have noticed the cyanide and many lives might have been saved. But they say that is too expensive.

Eventually Harvey was convicted of 36 murders. By his own estimate he might have killed 59. In spite of stories like these, the patient safety discussion will continue to call for "declaring safety as a priority" without doing anything substantive for the necessities of criminal law. They cannot uncover errors in an environment that cannot even uncover crime. In medicine the crimes have to be so large in scale that mere odds cause them to become known by happenstance. Deflecting liability and protecting reputations continues to be more important to medicine than protecting the lives of patients.

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Medicine will never clean up its act on its own. There must be freedom of speech for patients so that the community can force it to. We must be allowed to collect information and share it without being sued. And we must establish a complaint process that does not require patients or caregivers to complain to other people in medicine, perhaps instead to something like a state patients board.