Hospital Deaths and Medical Errors (OUTCRY Magazine #10)

The report which came out in late November, 1999 regarding 98,000 hospitalized patients died each year in the Unites States due to errors was very shocking, but was not unexpected. According to the report by the Institute of Medicine, many of the mistakes were due to "basic flaws in hospital operational system." For example doctors poor handwriting was one of the problems cited resulting in some patients' death due to the dispensation of the wrong medication or wrong dose.

Although the report is applauded for exposing serious problems in hospital operation which is far more than physicians bad hand writing, but was inaccurate in some other ways. Contrary to what was said regarding health care being behind regarding advancement in technology, health care had led the way in computerization of hospital system and utilization of complex diagnostic machines even before Internet was born. What went wrong was more than just bad physician's handwriting.

What Went Wrong in Hospitals

Hospital was based on authoritarian method  of administration for years because the professors always know more than the students regarding the subject matter. However, hospitals pushed the situation too far when business managers replaced clinicians in making medical decisions and patient's deaths start to rise. Many professionals who complained about the systems were directly and indirectly showed the exit door of the hospital. Subsequently, many hospital professionals left and took their experiences with them to other industries. Hospitals were left with inexperienced professionals to do dangerous work and cater for patients. What do we expect as the outcome? It was more obvious when many hospital across the nation replaced the judgment of the business manager who has never attended any medical school or had any medical training as the final say in hospital operation because of the demand for more profits. Consequently, many of the business managers made bad decisions which cost patient lives.

Hospital were Warned, but Refused to Listen

"The basic problem was, when a clinician was removed from heading a clinical department and replaced with a non-clinician, the essence and purpose of medicine were defeated. 

"Today with new trend to modify health care delivery system, if the hospital process of administration is not overhauled and monitored, whatever system put in place is doomed to fail.  page #90

"Removing a physician from heading a medical department like the laboratory is the error many hospitals across the nation would make. This malaise would grow like wild fire in hospitals ruining the health care to the point of economic disaster." page # 92

The above quotations come directly from the book Overcoming the Invisible Crime  352 pages, 1993 by 'Yinka Vidal, published by Lara Publications. This is the biography of a former hospital manager discussing some of the dangerous situations leading to many preventable patient deaths. Chapter four (pages 74 - 108) chronicled many situations leading to tragic consequences within the hospital. Vidal has been warning the system since 1993 when the book was first published, but they were not listening and so patients continue to die.

Solutions to Hospital Systemic Problems

Hospital must utilize the knowledge and experience of clinical experts to solve systemic problems within the establishment. At no time should a business manager be allowed to over rule a physician or a clinical expert. However, for the intervention to work, both business managers, physicians, nurses and other allied health professionals within the hospital must come to the bargaining table. In addition, interdepartmental committees should be set up to solve systemic problems incurred between the departments.

Critical evaluation should be made of how many patients a nurse or a physician can handle within a period of time. Similarly, how much work is expected of pharmacists, X-ray or lab techs before putting them under undue stress causing errors. It is well established that the more stress is generated due to work over load, the more the errors to be expected. When such errors happen patients die!

Hospitals must end the system of autocracy and be replaced with employee based solution interventions and strategies. Most hospitals who have adopted this style of management have experienced a boost in employees' moral and better work performance. It removes the "us against them" (administration) mentality and is replaced with "the contributing me" as part of the system.

Finally, patients themselves must be educated about their illnesses and be a part of the treatment with the physician. No patient must receive blind treatment without knowing the purpose, intended outcome and the resolution. Patients who accept blind treatment put their lives in grave danger. Click here to read more about patient's education

Man is by no means perfect and neither is any system created by human endeavors. Patients will occasionally be victims of human imperfections, but if we work hard to fix the systemic problems and not point accusing fingers, we in health care industry can reduce deaths from hospital mistakes. Is the hospital administration ready to listen?

Start patient education, get a copy of the book, Overcoming the Invisible Crime (Lara Pub. 800-599-7313). Here is a response to the book by a journalist: "A heart-rending story" Diane Sawyer, Primetime Life, CBS News.

Back to (OUTCRY Magazine #10)