Home - Patient Safety

Notes 9

Patient safety / Sex abuse / Crime in medicine


The issues:

Data sources are muzzled.
Exterior enforcement systems lack will and requisite knowledge and experience.
Interior enforcement systems are inclined to protect rather than manage.

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The healthcare economist, Dr. Stuart Altman, has an aphorism: Everyone's first choice is protecting their own turf, but everyone's second choice is doing nothing.

Economist Dr. Stuart Altman's aphorism more specifically says that universal healthcare coverage that protects one's turf is everyone's first choice — but everyone's second choice is to do nothing.
    Dr. Altman is one of the nation's leading experts in healthcare policy and economics. He is  a member of The Institute of Medicine of the National Academy of Sciences; a member of the Board of Overseers of the Beth Israel Deaconess Medical Center in Boston, Massachusetts; and, Co Chairman of the Advisory Board to the Schneider Institute for Health Policy at the Heller Graduate School, Brandeis University.





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Accountability: Patient Safety and Policy Reform
(Hastings Center Studies in Ethics.) Edited by Virginia A. Sharpe. 276 pp. Washington, D.C., Georgetown University Press, 2004. $49.95. ISBN 1-58901-023-X.





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removed from white wall of silence page

"There is no need to lie. Just don't find out.
If a patient tells you about it, you know they are all liars anyway."

Healthcare professionals simply refuse to accept that one of their own could be incompetent or evil. Speak to patients who became victims. Get their medical records. See what their doctors recorded when the patients reported what was done to them. Physicians almost never record "patient claims to have been injured by surgeon" or "poisoned by failure to check drug incompatibilities." Federal mandatory reporting laws require not only that they record it, but also that they report it. But they don't. Try it and see.







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No human being can be trusted to be all-knowing, all-seeing, all-wise. No human being can be trusted always to put your well being above all other considerations. Even parents have to divide their support between children, spouses, their own parents, and the needs of the community. Even doctors have bad days and bad motivations. That is one reason that crimes against patients are tolerated. The reason the public accepts it is, in part, that patients assume doctors always put the well being of patients above all other considerations.






Kristina A. Fox
The operation was performed on Kristina A. Fox in Portland, Oregon in the fall of 1998. It was supposed to be a routine, minimally invasive laparoscopy to relieve a painful gynecological condition. Stray electric arcs from the instrument burned other parts of her internally leaving her with a malfunctioning bladder and disabling pain that prevent her from working or bearing children. She's had 13 operations so far to try to survive the injuries. The original problem could have been prevented with a $1000 device that is the equivalent of a ground fault circuit interrupter that detects stray electric arcs from laparoscopic devices. A former operating room nurse, Trudy L. Hamilton, suffered a similar injury in 1991and has been treated many times since to try to cope with the damage. She said, "I don't think people who say they aren't seeing this problem are lying. I think they are grossly misinformed." How difficult is it for them to become better informed with all the inertia to cover up? This particular article is mentioned here not because I have the answer to solve it, but because of the view it gives of medicine as a whole. Hospitals are under no obligation to collect such date, and have a huge inclination not to. What that says about them as overseers of patient safety is what must be addressed.

The article was by Barnaby J. Feder in the New York Times on March 17, 2006. At the time of this writing it was accessible at this link.

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The Oakland Tribune
Newspapers don't keep their articles on the web forever, but at the time of this writing the link to their article about this is:

If that no longer works, the link to their homepage is this:

What's below is taken from a 03/09/2006 article about it written by Susan McDonough, a staff writer.

A drunk Dr. Frederico Castro-Moure, chief of neurosurgery at Highland Hospital Oakland, was arrested after getting combative in an operating room and later taking a swing at officers, according to the Alameda County Sheriff's Department.

Castro-Moure was arrested just after 8:30 p.m. by sheriff's deputies for being under the influence of alcohol and interfering with the duty of officers, according to a Sheriff's Department report. Deputies believed the doctor was drunk beyond the ability to care for himself and others, Lt. Jim Knudson said. According to a witness who gave authorities details of the incident, Castro-Moure's angry tirade started when hospital staff questioned his medical authority.

The doctor was on call when Highland received a trauma patient who had fallen two stories and landed on his feet, the witness said. Casto-Moure wanted to operate immediately but was told the instruments would have to be sterilized first. The doctor then threw a "huge fit," according to the witness. He began yelling and swearing at staff, telling them "he didn't (expletive) care what hospital procedure was." The charge nurse refused to admit the patient into the operating room until the instruments were re-sterilized, the witness said. The doctor began intimidating the charge nurse by punching his fist into his hand while walking toward her, according to the witness. When it appeared the doctor would follow her into a private locker room, someone on staff alerted sheriff's deputies at the hospital to the situation. When deputies arrived at the operating room, Castro-Moure came around the corner.

"What the (expletive) do you want?" he screamed at the deputies, one witness reported. "Do you know that I am a (expletive) doctor, and I'm going to do what I want," he said, according to the witness.

The officers tried to calm the doctor, but Castro-Moure resisted, deputies reported. He shoved one officer and took a swing at another. Deputies said they had to wrestle the doctor to the ground to handcuff him.

Back to Castro-Moure









BMJ (British Medical Journal) 2000;320:759-763 ( 18 March )

Clinical review

Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems

by Paul Barach, clinical fellow, Stephen D Small, assistant anaesthetist.
Department of Anesthesia and Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA

Reducing mishaps from medical management is central to efforts to improve quality and lower costs in healthcare. Hundreds of thousands of patients die unnecessarily each year in medicine (see Preventable Deaths). When they first estimated that it was only 100,000 patients and it was estimated that the annual cost of that was $9 billion. Underreporting of adverse events is estimated to range over 90% (see Medical Reporting). This annual toll exceeds the combined number of deaths and injuries from motor and air crashes, suicides, falls, poisonings, and drownings. Many stakeholders in healthcare have begun to work together to resolve the moral, scientific, legal, and practical dilemmas of patient harm problems. To achieve this goal, they call for an environment fostering a rich reporting culture to capture accurate and detailed data about nuances of care.

There is never going to be a culture rich in reporting in medicine. This is one of the fairytales they tell themselves when they want to believe they are doing something without doing anything.

At the time of this writing, the full article could be seen at the BMJ web site at this link:

to the paragraph that linked to here








The police have a policy
When I took a case to the police, they repeated over and over that they have a policy of never duplicating the investigation of another agency like a state medical board. I questioned it, but they kept repeating it. "That's just our policy." If I call the police without presenting a case and ask about that policy, I'm told that they would have a hard time dealing in hypotheticals. 

I am trying to determine if it is a written policy or one of those things that some departments assume. I am working to get access to a police department's Policy and Procedure Manual as a beginning of that investigation. Whether or not it is written, and whether or not the police will confirm that it is a policy, I personally have been told by more than one police officer that they would not duplicate investigation that the state medical board had accepted.

But, of course, the police also insisted that if it happened in a hospital, then it was civil and not criminal. The amount of nonsense that police will repeat and argue in order to thwart a complaint being brought by a victim of a crime in medicine is perplexing. Patients who are victims need help, not perplexities. We need a phone number for them to call.

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According to Stephen G. Pauker, M.D. in the New England Journal of Medicine, Volume 355:218-219 July 13, 2006 Number 2, the core problem in hospitals is the inability of the system and its managers to solicit and integrate the knowledge and experience of front-line workers (physicians, nurses, and support staff).

Any way you look at it, healthcare workers won't report. Even federal mandatory reporting laws have had no effect on this.

Stephen G. Pauker, M.D.
Tufts–New England Medical Center
Boston, MA 02111

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Quotes from Arthur Levin and Charles B. Inlander are from an article in the New York Times, July 21, 2006 called "Report Finds a Heavy Toll From Medication Errors" by Gardiner Harris.

Even though, according to the report, most drug errors do not lead to injury, they are so widespread that hospital patients should expect to suffer one every day that they remain hospitalized.








MARKER, by Robin Cook. (Berkley, $9.99.) A pair of New York City medical examiners investigate a series of hospital deaths following routine surgery. Jaz, the individual responsible for all of the unexplained deaths is a frustrated nurse psychopath. She is obsessesed with physical fitness and dedicated to maintaining her edge of physical strength. "Jaz" is paranoid to the extant and has been contacted by two mysterious and unknown individuals to do "contract" terminations of select patients in the hospital where she is employed. She is highly successful with her terminations and is building her savings to advance her lifestyle.






Liabilities, errors:
seven years (on average) of legal tangling, risk of financial ruin as well as possibly losing the ability to continue practicing medicine


Among the precedents for complaining about specific companies and people online is:






According the the Australian government 11% of all deaths in Australia result from medical errors.

A British journal said that 10% of all patients in the hospital are harmed.  




October 31, 2006

some hospital administrators and experts in human factors argue that aviation safety principles are not wholly transferable to health care. “Medicine is a more complex environment with more professionals interacting than in aviation,” said Robert Helmreich, professor of psychology at the University of Texas at Austin and director of its Human Factors Research Project, which studies team performance and the influence of culture and behavior in aviation and health care.

The definition of an error in health care, Professor Helmreich said, is “fuzzier” than in aviation, where it is easier to identify a “foul-up” and who was responsible. Health care providers’ fear of litigation and losing their medical licenses also hinders the honest reporting of mistakes, whereas aviators are often inoculated against punishment if they promptly report incidents to the authorities. Training programs developed by pilots without knowledge of health care realities can be “appallingly bad,” he said.

More successful are programs developed by consulting firms like LifeWings in Memphis and the Surgical Safety Institute in Tampa, Fla., both of which have professional pilots and physicians developing their training materials and serving on their advisory boards.

Some institutions, like Johns Hopkins, have created their own in-house training programs and safety structures based on aviation. “Aviation provided us with the ideas, which we then modified for health care as well as our particular situation,” said Dr. Peter Pronovost, the director of the Center of Innovation in Quality Patient Care at Johns Hopkins.



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"I also have learned with great pain that the vilification of patients who sue continues after trial. Because we sued, healthcare providers in our hometown refused to treat us in a manner that I was surprised to learn was legal. There is one pediatric neurologist in the state of Idaho, and he informed us by registered letter that he would not treat Cal even in the event of an emergency. When Pat experienced a leakage in spinal fluid while recovering from spinal surgery, we were informed that the hospital where Cal had been injured would not admit him. We were forced to airlift Pat out of state at a cost of $13,000. He needed six stitches, which a resident performed."
July / August 2007
Patient Safety and Quality Healthcare newsletter
We're Not Your Enemy
An Appeal from a Consumer to Re-imagine Tort Reform
By Susan S. Sheridan, MIM, MBA, and Martin J. Hatlie, JD

Just try to find anyone in healthcare who is aware that they are part of a system that works this way.

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from A Basic Hospital To-Do List Saves Lives
by Jane E. Brody
The New York Times, Tuesday, January 22, 2008, page D7

When inserting a central venous catheter, doctors should do the following:
1. Wash their hands with soap.
2. Clean the patient's skin with chlorhexidine antiseptic.
3. Put sterile drapes over the entire patient.
4. Wear a sterile mask, hat, gown and gloves.
5. Put a sterile dressing of the catheter site.

. . . in the crush of crisis medicine, one or more of these steps is often neglected . . . What made the program work in Michigan was continuous - and anonymous - collection of data.


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There needs to be something analogous to the Consumer Product Safety Commission that looks at the world from the patient's perspective, with the mandate to look at abuses, collect data about them and recommend changes.


The organizations springing up to try to help patients have no official status and no authority and usually little expertise to be of use to injured patients. At Links for Injured Patients I give a rundown on some of them, like the review about the Josie King Foundation that shows why so little progress is made even in the face of impressive efforts. There needs to be an official institution with injured patients on the board who understand what the world is like for injured patients. In Great Britain they have figured that out (see Reform).

Healthcare professionals cannot represent the interests of patients. They believe each other and they don't believe patients. It is a circle that reinforces their own self-serving view of the world and leaves them complacent about hundreds of thousands of unnecessary deaths per year - an acceptable cost to them.

One of the themes of this site is why this will continue to be the case as long as doctors and nurses are in charge of patient safety. If I rewrite it three times a year for the next ten years, maybe I'll find a way to make my point in less than forty thousand words, but even then I doubt it can be done without offending people in medicine, which partly is why it is so difficult to communicate about this. There is a virtual agreement not to ask the big questions or look at the fundamental problems so as not to offend anyone in the medical community. Everywhere in patient safety people are polishing varnish as though the wood is not rotten. Facts and cases have made no impression on current assumptions. I am searching for how to speak in the face of that. One of my attempts is through fiction - muckraking, I guess - like this chapter in progress.

In the meantime, the medical community enjoys perverse incentives and comfortable blindness. The people who are suffering not only are not in charge but are not even heard for the most part. Autopsies and honest tracking of the long term results of care would be two ways for medicine to start listening. Instead, wisdom comes from the collective agreement of people who get paid no matter what the outcome for patients. That doesn't work in any field.



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3% get lawyers
Harvard researcher Dr. David Studdert in a 1999 study of 14,700 medical charts found that of the patients who suffered negligent injury, 97% did not sue.

However, Studdert studied only grievances of which a record had been made. According to the Department of Health and Human Services (and others, see Medical Reporting) only 2% of adverse events are reported accurately by health care professionals. What Studdert is saying is that of the 2% of patients whose injuries are accurately reported in medical charts, 3% can get lawyers. 2% of 3% is .0006%. So of the patients with legitimate grievances, .0006% file suits. When the numbers are so small, does it matter exactly where the decimal is? It is so close to zero.

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1.5% report rate of adverse events
This fact is cited in:
Making Health Care Safer
A Critical Analysis of Patient Safety Practices
Prepared for:  Agency for Healthcare Research and Quality, Contract No. 290-97-0013
Prepared by: University of California at San Francisco (UCSF)-Stanford University Evidence-based Practice Center
The full report is available on line at: http://www.ahrq.gov/clinic/ptsafety/chap4.htm

Chapter 4. Incident Reporting
Heidi Wald, M.D., University of Pennsylvania School of Medicine
Kaveh G. Shojania, M.D., University of California, San Francisco School of Medicine

"Most hospitals' incident reporting systems fail to capture the majority of errors and near misses. Studies of medical services suggest that only 1.5% of all adverse events result in an incident report and only 6% of adverse drug events are identified through traditional incident reporting or a telephone hotline. The American College of Surgeons estimates that incident reports generally capture only 5-30% of adverse events. A study of a general surgery service showed that only 20% of complications on a surgical service ever resulted in discussion at Morbidity and Mortality rounds."

0% of adverse were events reported in this study
Among 228 patients admitted to the medical unit of a Boston teaching hospital, the patient-reported adverse event rate was nearly 9 per 100 admissions. Serious injuries were uncommon, but two thirds were judged preventable. In addition, 4% of patients experienced near misses. Few patient-reported incidents were identified in the medical record, and none were submitted by clinicians to the hospital's incident-reporting system.
The conclusion of the article was that inpatients can identify adverse events affecting their care. Many patient-identified events are not captured by the hospital incident reporting system or recorded in the medical record. Engaging hospitalized patients as partners in identifying medical errors and injuries is a potentially promising approach for enhancing patient safety.
All 19 nurse respondents endorsed the statement that medical inpatients can identify problems such as errors and injuries, and that they should continue to be asked about problems, injuries, and errors experienced in the hospital.
A significant limitation of most studies is the ascertainment of adverse events based on chart review alone. Many adverse events are not recorded in the medical record, a finding attributed to variable standards for documentation, clinician unawareness or oversight, and concern about liability exposure.
A study in ambulatory care showed that chart review detected fewer than 11% of adverse drug events. . . patient contact represents an important detection approach.

From an article called "What Can Hospitalized Patients Tell Us About Adverse Events? Learning from Patient-Reported Incidents"
by Saul N. Weingart, MD, PhD, Odelya Pagovich, BA , Daniel Z. Sands, MD, MPH, Joseph M. Li, MD, Mark D. Aronson, MD, Roger B. Davis, ScD, David W. Bates, MD, MSc and Russell S. Phillips, MD
in the Journal of General Internal Medicine, Volume 20, Issue 9, 2005, pages 830-836
The abstract can be viewed at: http://www3.interscience.wiley.com/cgi-bin/fulltext/118700875/HTMLSTART


Eight Years After IOM Report: Patient Reports are more Reliable than Hospitals
Daniel R Longo, ScD, Virginia Commonwealth University School of Medicine says that any study that does not take patient reporting into account is severely underestimating the extent of problems in the nation’s hospitals.


See also:
The Silence
by Michael L. Millenson
in Health Affairs, 22, no. 2 (2003): 103-112

He says that there remains within healthcare a refusal to confront providers’ responsibility for the problems. He suggests initiating emergency corrective-action comparable to Flexner’s crusade against charlatan medical schools.


For a personal story about it, see also:
The aftermath of a 'never event'
A child's unexplained death and a system seemingly designed to thwart justice

By: Dale Ann Micalizzi
Modern Healthcare March 3, 2008

"The immediate silence from the physicians, nurses and the hospital's chief executive officer was deafening. I felt connected with the staff, having worked for an HMO in the area for a number of years. Now, all I was seeing was a classic pattern of denial and defense."

In the same breath that healthcare professionals insist that they and their colleagues report everything, they say that "of course you have to protect yourself from lawsuits" - which is done by not reporting anything.


See also:
Patients Identify Undocumented Adverse Events
Telephone interviews with 201 patients after ED discharge identified 10 adverse events that had not been reported in their medical records.
— Kristi L. Koenig, MD, FACEP in Journal Watch Emergency Medicine September 26, 2008



The reliability of medical record review for estimating adverse event rates
According to this article, when negligence is involved, an adverse event is much less likely to be reported.
Authors: THOMAS Eric J. ; STUDDERT David M. ; BRENNAN Troyen A. ;
Authors Affiliations:
Brigham and Women's Hospital and Harvard School of Public Health, Harvard University, Boston, Massachusetts, Medical University of South Carolina, Charleston, South Carolina, University of TexasHouston Medical School, Houston, Texas,
Background: The data used by the U.S. Institute of Medicine to estimate deaths from medical errors come from a study that relied on nurse and physician reviews of medical records to detect the errors. Objective: To measure the reliability of medical record review for detecting adverse events and negligent adverse events. Design: Medical record review. Setting: Hospitalizations in Utah and Colorado in 1992. Measurements: After three independent reviews of 500 medical records, the following were measured: reliability and the effect of varying criteria for reviewer confidence in and reviewer agreement about the presence of adverse events. Results: For agreements in judgments of adverse events among the three sets of reviews, the K statistics ranged from 0.40 to 0.41 (95% CIs ranged from 0.30 to 0.51) for adverse events and from 0.19 to 0.23 (CIs, 0.05 to 0.37) for negligent adverse events. Rates for adverse events and for negligent adverse events varied substantially depending on the degree of agreement and the level of confidence that was required among reviewers. Conclusion: Estimates of adverse event rates from medical record review, including those reported by the Institute of Medicine in its 2000 report on medical errors, are highly sensitive to the degree of consensus and confidence among reviewers.
Journal Title:
Annals of internal medicine ISSN 0003-4819, 2002, vol. 136, no11, pp. 812-816 (16 ref.)
Published by American College of Physicians, Philadelphia, PA,


See also:
"Disclosing unanticipated outcome to patients: The art and practice"
by Thomas Gallagher, Lucian Leape and others
Journal of Patient Safety, September 2007

". . . available evidence suggests that open communication of unanticipated outcomes occurs infrequently."



The federal Agency for Healthcare Research and Quality reported in May that the rate of adverse events—a key measure of patient safety defined as unintended harm during medical care—has risen by about 1% in each of the past six years, in part because of a rise in hospital infections. Other studies show that one in seven hospitalized Medicare patients experience one or more adverse events. One in 15 hospitalized children are harmed by medication errors. And that's just the ones that get recorded. Imagine how many there really must be.



See also:
Why not just do a search on something like adverse event medicine report rate and similar strings?



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More from her same article above:
Dale Ann Micalizzi of Justin's Hope

"I never wanted lawyers involved. I never wanted to question a physician's judgment or a hospital's care. There was no other option available to us. . . "

". . . it isn't worth a lawyer's time to accept such a case unless the evidence is overwhelming and an easy settlement attainable.

"A federal judge in Washington, who is a family member, recommended that we educate ourselves on how such cases work. Traveling several hours west, my husband and I met with a law professor and attended classes at a law school to learn the rules of the game."

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Patients are five times more likely to die from visiting hospitals than from not having health insurance, according to the not-for-profit Committee to Reduce Infection Deaths. And yet to hear the presidential candidates talk about it, insurance is the problem. The patients who are dying do not have a place to complain about problems or a voice to influence legislation or even a way to make known to candidates what the issues are in healthcare. We need a way. We need a voice. We need a professional institution representing and protecting and helping patients.









Medicine is a sick patient whose reasoning and judgment often are untrustworthy. It is apt to slide back into the same old destructive habits without some firm and concrete correctives in place.




One patient, who called after seeing this site, had spoken to a coroner who said he would never go to "that" hospital. Why can't patients know what he knows?