A Four-Year Study: War on Medical
Errors is Failing Due to Lack of Initiatives of Health-care Executives and Failure of
Enforcement Policies
Health-care
Crisis in America – Beginning Stage of a Meltdown
Florissant,
MO. Nov. 17, 2003: This four-year ongoing study on solution implementation shows that
medical errors continue to kill patients at an alarming rate because of the failure in
leadership of health-care executives and management crisis embedded in the health-care
institutions. Most levels of solution interventions to medical errors lead to a failure
due to the absence of an enforcement policy. This ongoing study already interviewed over
2,000 health-care workers, and evaluating over 12,000 initiatives sent to health-care
executives. In most of the institutions where errors continued, quality improvement is
given to a staff member who has neither the administrative power nor the resources to
improve quality of patient care. Even some of the employees who pursue medical errors with
vigor are continuously being persecuted by fellow workers and in some situations, hospital
executives have joined in the persecution of the quality improvement officers. Patients
are dying needlessly because some hospital executives are spending more time raising money
for charitable events than the time needed for quality improvement. As long as money
remains the central piece in health-care services, the value of human life will continue
to take a back seat. To complicate the matter, by asking these executives and MDs the
solutions to the problems of errors, is like asking a patient for the cure to his or her
illness. Hospitals executives, MDs and research experts from prestigious institutions are
part of the major problems why medical errors continue! Both physicians and health-care
workers are angry at the system. The system of delivering care is broken down. The cost of
care continues to skyrocket out of control partly due to waste, misadventure, medical
errors and fraud. Physicians are losing malpractice insurance due to rising cost.
Insurance companies are screaming because they are losing millions of dollars to
malpractice lawsuits. Hospital emergency rooms are closing across the nation. The fight
over health-care insurance coverage for employees due to rising cost has created a
battleground between workers and their employers. Whether we want to admit or not,
America’s health-care system is at the beginning stage of a melt down!
Our study panel appealed to AHRQ,
a government’s organization supposed to be distributing money for research project on
medical errors to pay more attention to those working on the process-lines at local
health-care institutions. They have spent over half a billion dollars since 1999 on
medical errors. No progress has been achieved. Health-care executives do not have answers
to medical errors. They are the major problem! The solutions to medical errors can be
identified from those who work on the process-lines of patient care, but the initiation
and support for searching for solutions have to be done by hospital executives. Based on
the result from this study, hospital executives inadequately responded to initiatives to
reduce medical errors. Even in cases where problems are identified, solutions designed and
implemented, lack of an enforcement system leads to solution implementation failure. This
is where the role of hospital executives is very critical in reducing medical errors. As
long as those hospital executives refuse to talk to those people working on the
process-line because these workers are supposed to be beneath them, medical errors will
continue to kill patients unabatedly. Many of the hospital executives believe that all
they have to do is press a remote control button in their office by a process of
delegation and all problems will be solved. It won’t happen with medical errors. A
few hospital executives have achieved success by working directly with quality improvement
officers significant improvement in their institutions to reduce errors.
In December 1999, the Institute
of Medicine (IOM) reported that thousands of innocent Americans are dying annually due to
preventable medical errors. Federal government first voted $50 million to fight medical
errors. The amount progressively increased yearly to $100 million in 2003. From 1999 to
2003 an estimate of over $400 million has been spent on medical errors. With private
donations added to government grants since 1999, more than $600 million has already been
spent to fight medical errors.
Despite all the millions of
dollars spent on medical errors, patients are still dying of simple systemic failures. In
October 8, 2003, New York Times reports the results of a research study by Agency
for Health-care Research and Quality in an article, “Med Complications May Cost $9B
Per Year.” The article reports that postoperative infections from surgical wounds and
other preventable complications kill more than 32,000 in US hospitals costing $9 billion
annually. The new report compiled data from 994 hospitals in 2000. The most serious
complication is post-surgery sepsis – blood infection in 2,592 patients with $57,727
extra cost per patient. According to Associated Press report of Feb. 2003, Jesica
Santillian spent three years waiting for an organ transplant. When it was time for the
transplantation, she received the wrong type at Duke University Medical Center, one of the
leading health-care institutions in the nation. Jesica died a few weeks later. Her blood
type was O-positive, but her donor type was A-positive. The transplanted organs were
incompatible. According to one of the warnings in our report on page #139 released early
in 2002 in the book, 101 Ways to Prevent Medical Errors, the systemic failure which
killed Jesica was already discovered and released to the medical community, Congress, the
White House, the Department of Health and Human Services, JCAHO, American Hospital
Association, etc. According to St. Louis Post Dispatch of October 15, 2003, Georgia
Wood sued Barnes-Jewish Hospital and Washington University School of Medicine because her
husband had a successful heart surgery in February 2002 and received two units of
mismatched blood, he died months later.
John Monk reports on medical
errors (thestate.com, April 02, 2003) about Bob Andrews, a prominent businessman who
obeyed his doctor’s order and took two medications together. Within a few hours, he
dropped dead. The physician made an error because the medications were not supposed to be
taken together. Known drug interactions caused the patient’s instant death. Linda
McDougal was told she had breast cancer and both breasts were removed (CNN {Press Report,
New York, 2003). It was later discovered that a mistake was made because her pathology
slide was mis-matched with that of another patient at the United Hospital in St. Paul,
Minnesota. The pathology diagnosis was wrong. Stephen Smith reports in his article,
“Hospital Baby Mix –up Renews Old Fears,” (Boston Globe, September 26,
2003) about a mis-identified baby. A mother was accidentally given a wrong baby to
breast-feed. According to the report, the error was discovered before the woman started
breast-feeding the baby. It was a case of a patient mis-identification known to be a
serious problem in many hospitals. On evaluating these errors one thing is evident, these
errors are caused by simple systemic failures.
This study identifies the reasons
for slow progress in medical errors while other experts are already raising the red flag
of intervention failure. Dr. Donald Berwick, the CEO of the Institute of Healthcare
Improvement states that errors continue because of failures of health-care institutions to
act on recommendations given by the IOM study. He indicates in his Washington Post
article of 2003 that there is a lack of coordination among hospital departments to fix
errors. In Damon Adams article, “Push to Improve Patient Safety Slow Going,” (Am
News, May 7, 2001) that both physicians and hospitals are very resistant to adopt the
recommendation by IOM. Only 7 percent of the physicians had adopted automated systems for
prescribing drugs. Sandra G. Boodman (Washington Post, Dec. 2002) reported that
there is no end to medical errors after three years of the landmark report found pervasive
medical errors in American hospitals, little has been done to reduce death and injury. She
indicates that there is a lot of talk but no significant progress. Resistance from
physicians and hospitals to mandatory reporting and other IOM recommendations, and lack of
oversight by the federal government are responsible for continuous medical errors. Even
while President Bush was addressing the American Medical Association’s National
Advocacy Conference in March 2003, he stated that, “Patient safety is improved when
doctors and nurses exchange information about problems and solutions.” How can
doctors and nurses exchange information while they are constantly fighting?
As
part of the solution intervention, in summer 2004, we are going to amplify our national
campaign on medical errors by releasing our latest research report in the book, Managing
Crises on the Job – Reported For Working on Duty and Reprimanded For Working Too Hard
- An Interminable Journey of Fixing Medical Errors by Yinka Vidal, published by Lara
Publications. In October 2004, we are inviting hospital executives to come and listen to
those who work on the process-lines of health-care services. We are also taking the
campaign directly to health-care institutions across the nation. The Chicago national
conference in 2004 is an amplification of our national campaign on medical errors. With
your support, we hope this national campaign will attract the attention of all health-care
executives and motivate them to make war on medical errors their number one priority.
Based on the latest results of
our ongoing study and campaign on medical errors, institutions with substantial progress
on medical errors were successful under the combined driving forces of both the hospital
CEOs and the medical directors. Even though it is very crucial to involve those working on
each of the process-line of patient care, significant improvement is achieved where
health-care executives champion the war on medical errors in their respective
institutions. The present slow progress on medical errors is directly related to the
absent participation of health-care executives in various health-care institutions.
From 1999 to 2003 our research
projects discovered the problems and solutions to persistent medical errors in health-care
institutions. The study is designed to identify problems leading to medical errors, design
solutions, and implement corrective action to reduce medical errors. The result of this
study is due for release in summer of 2004. A 34-page summation report is due for release
in October 2003 and will be placed on our site after release at: research
summation report
Key Observations of the Four-Year
Study:
1. Medical
errors are caused by simple systemic failures and not by a complex system.
2. People
who work on the process-line are able to re-design their work environment to prevent
errors than any manager or supervisor.
3. Those
who are currently working to fix medical errors are detached from the real problems. They
are therefore not hitting the core of the systemic failures because they excluded those
working on the front-lines.
4. Hospital
executives and physicians are two groups at odds with each other leading to progress
stagnation and indifference to the issue of medical errors. This causes impotence of
action.
5. Resistance
to solution implementation retards the progress of fixing medical errors in the absence of
an effective enforcement system.
6. For
any solution strategy to work, the entire program must be orchestrated, supported and
motivated by the hospital CEO, medical director and the director of nursing working
together as a team.
7. Many
of the hospital executives despite repeated appeals are unresponsive to initiatives to
reduce medical errors. The job of quality improvement has been delegated and abandoned at
the desks of quality improvement officers who receive inadequate support from the hospital
administration. Most of them lack power to enforce corrective actions.
8. Major
management conflicts exist within health-care institutions making solution intervention
extremely difficult. Fixing medical errors takes a lot of work to achieve success.
Progress cannot be accomplished in such a chaotic work environment.
9. Physicians
need to treat nurses and other health-care workers as partners in healing patients and not
as housemaids.
10. Without knowing what is
actually happening on the process-line of patient care, any designed solution is doomed to
a failure. Solution strategies without
involving the frontline workers will not be successful.
11. Hospital executives need to
be motivated so they can in turn motivate their employees and help to champion war on
medical errors in their respective institutions.
12. Instead of fighting medical
errors, identifying systemic failures, policing other physicians to improve the quality of
patient care and reducing litigation, some physicians are busy fighting the insurance
companies and lobbying Congress.
The goal for this Chicago
conference is to bring a minimum of 500 health-care executives to the conference free of
charge as part of the incentive package. They will listen to the challenges faced by
health-care quality improvement officers while trying to fix medical errors. They will
hear the concerns of those who work on the process-lines of care and also listen to a
series of those effective strategies to reduce medical errors. They will also hear why
solution implementation fails in the absence of an enforcement policy. For the most part,
the seminar is an opportunity to appeal to health-care executives about their important
role in leading the war on medical errors in their health-care institutions. This seminar
will continue until all the 10,000 hospital CEOs have attended the conference.
If the IOM report is accurate,
since 1993, after ten years since we first reported about medical errors to Congress and
President Clinton in the book, Overcoming the Invisible Crime, between 480,000
to 980,000 patients have died and millions have been maimed as a result of preventable
medical errors with a total loss in revenue in excess of $338.4 billion. This data
is provided by www.ahcpr.gov Health-care cost,
employee health insurance and malpractice insurance premiums are going up at an alarming
rate partly due to medical errors. If we can reduce medical errors, the wasteful spending
and fraud within the industry, perhaps we can slow down the rate of growth of health-care
cost.
Please click
here for the research summation report of a four year solution implementation study.
The book, Managing Crises on the Job – Reported for Working
on Duty and Reprimanded for Working Too Hard -
