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. Resistance at most levels of solution intervention leads to a failure in the absence of an enforcement policy. This 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. Instead of being helpful, some 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. Our request asking both Congress and the White House to declare war on medical errors to gain an increase attention of hospital executives has not been successful. Nearly all the news reports on medical errors have ignored many of us working on solution implementation and the daily difficult struggles we face. Whether we want to admit or not, America’s health-care system is at the beginning stage of a melt down!

Because most research grants were going to teaching institutions, this research panel appealed to AHRQ, a government’s organization supposed to be distributing grants for research on medical errors to pay more attention to those working on the process-lines at local health-care institutions. Over half a billion dollars has been spent on medical errors since 1999. No progress has been achieved. Health-care executives do not have answers to medical errors. 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 in three major studies. Even in cases where problems are identified, solutions designed and implemented, lack of an effective enforcement policy leads to a failure. This is where the role of hospital executives is very critical in reducing medical errors. As long as they 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 the quality improvement officers and frontline workers with significant improvement in error reduction.

In December 1999, the Institute of Medicine (IOM) reported that thousands of innocent Americans are dying annually due to preventable medical errors. The 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, 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. St. Louis Post Dispatch of Oct 27, 2003 reports the death of George R. Buzz Westfall, the County Executive. He died of staph infection that did not respond well to antibiotics. Dr. Douglas Zweig his doctor said he did not know how the infection entered his system. Could Westfall’s death been prevented? 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 two things are evident. One, nearly all these errors are caused by simple systemic failures. Two, all the big projects, celebrity researchers, and money spent on medical errors did not stop any of the errors.

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 adopting the recommendations 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. 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 and the failure or absence of enforcement policies.

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

Here are 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 better 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 of patient care.
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 policy.
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 with continuous administrative crisis.
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 the 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 litigations, 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. 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 visit our web site at: www.101waystopreventerrors.com for full report. The book, Managing Crises on the Job – Reported for Working on Duty and Reprimanded for Working Too Hard by Yinka Vidal is due for release in summer 2004. Reserve your review copy by faxing your request to Lara Publications at 314-653-6543.

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