Get tough on medical errors, conference told

Economist Uwe Reinhardt, PhD, calls on health care safety and quality activists to stop being so polite.

By Andis Robeznieks, amednews staff. Dec. 22/29, 2003.

Public pressure and government action are needed to make the health care industry more serious about improving quality and patient safety, and a better job of reporting health care issues by the media could ratchet up the pressure.

That was the message delivered by speakers at the Joint Commission on Accreditation of Healthcare Organizations' recent "Decisions That Count" three-day conference on health care quality and patient safety in Chicago attended by physicians, nurses, attorneys and health care managers.

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"The American media is failing us with health care," said Princeton University Professor of Political Economy Uwe E. Reinhardt, PhD.

Dr. Reinhardt wondered what the public would do if news anchors mentioned in every broadcast that "another 120 people died needlessly" that day because of medical errors or some other quality failure.

He also declared that "the politeness has to leave the debate" and told the audience that they must get tough and not worry about being liked.

But all people can expect the private sector to do is talk and "nibble at the edges," Dr. Reinhardt said, so it will be up to the government to make changes that will improve quality.

80% of hands-on patient care in hospitals is delivered by someone other than a physician.

National Quality Forum CEO Ken Kizer, MD, said it's time to recognize that "health care is a team sport" and noted that 80% of hands-on patient care in hospitals is delivered by someone other than a physician. He said simple things can be done to improve quality such as serving more nourishing food, requiring caregivers to get flu vaccinations and making sure hospital staff wash their hands between patients. George J. Annis, who chairs Boston University's Dept. of Health Law, cited efforts to get doctors to wash their hands as an example of how low the quality bar has been set.

Author and Robert Wood Johnson Foundation Senior Program Officer Rosemary Gibson called the 240 people in attendance "early adopters" and mentioned how some hospitals still discourage staff from applying for grants to study medical errors out of fear the research will put the institution in a bad light.

"People are counting on you, and they are very, very grateful for your efforts," said Gibson, whose book Wall of Silence tells the stories of people and families affected by medical errors. "We need to change the public's norms about what's acceptable." She told the audience that they needed to start building a broad base of public support if they wanted action to be taken. Gibson gave several recommendations on how to do this, including "putting a face" on the people affected by medical errors and getting people to evoke their own experiences regarding how medical errors have affected them or someone close.

A traumatic mistake

Physicians are also affected by medical errors, and Arnold A. Zeal, MD, with the Jacksonville-based Neurosurgeons of North Florida, told his story during a one-day conference on eliminating wrong-site surgeries that JCAHO sponsored just before its conference on quality and safety.

While performing a lumbar disc operation on another physician three years ago, Dr. Zeal was unable to find a bone fragment that had been causing the patient discomfort. Only after the surgery was completed did he realize he had operated on the wrong side of the patient -- who was immediately returned to the operating room after the error was discovered.

Dr. Zeal said the patient didn't appear worse for wear from the incident and went home the next day, returned to work in two weeks, and was playing tennis again in three months.

"The patient did fine -- probably better than I did," said Dr. Zeal, adding that he still has nightmares about the error and is embarrassed whenever he sees his former patient in a work or social setting.

The incident was investigated by the Florida Board of Medicine, who ordered Dr. Zeal to pay a $10,000 fine and cover the cost of the investigation. He said he also was troubled by the fact that there was no effort made to prevent such an event from happening again.