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December 14, 2007 NEWSLETTER
Doug Wojcieszak, Founder & Spokesperson
Contact phone/e-mail address: 618-559-8168; doug@sorryworks.net
THIS WEEK'S EDITION:
- Military week for Sorry Works!
- Canadian Article on Disclosure
- Docs not reporting errors/disclosure program can help
MILITARY WEEK FOR SORRY WORKS!
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This was military week for Sorry Works!
Doug Wojcieszak, SW! founder and spokesperson, delivered two speeches on disclosure and apology to Womack Army Hospital at Ft. Bragg North Carolina and the Dorn Veterans Administration Medical Center in Columbia, SC. Both presentations were well-received. It was exciting to make these presentations since the disclosure movement was started at the VA Medical Center in Lexington, Kentucky and the Sorry Works! e-newsletter has numerous military subscribers. Our troops deserve the best, including the whole truth after adverse medical events. They deserve answers and fixes and it's encouraging to see the progress we are making in the military's medical community.
If you are interested in a Sorry Works! presentation, e-mail doug@sorryworks.net or call 618-559-8168.
CANADIAN ARTICLE ON DISCLOSURE
Below is an article on lack of disclosure involving a patient in the Canadian healthcare system. Though the Canadian healthcare system has many differences with American healthcare, the story below and the cultural issues covered are a match with American healthcare. Sorry Works! has many supporters in Canada, and disclosure is a hot topic north of the border, but as the article illustrates we still have a long way to go...north and south of the border.
The Daily News (Nanaimo)
Thursday, November 29, 2007
'Routine' surgery causes injury; A Parksville woman demanded answers, and was shocked at what she found
By Paul Walton
There is no such thing as "minor," "routine" or "risk-free" surgery. Ask Rhonda Nixon. In June, the Parksville woman went into Nanaimo Regional General Hospital for a surgical procedure that -- if it went well -- would have her back on her feet with little inconvenience. But it didn't go well. Nixon, 41 years old and with two teenage boys, ended up in the NRGH intensive care unit for 10 days, and it was another 20 days before she left the hospital.
It was a year before Nixon was well enough to return to work. And it was only then that she learned details about what went wrong in her surgery. Medical staff admitted to what in medical jargon is an "adverse event" -- some even saying they were "sick about what happened" -- but little more.
It would be nearly a year before she learned they had perforated a bile duct, considered one of the worst complications arising from the type of procedure Nixon underwent.
"Nobody ever explained it to me, in the hospital or out of the hospital, the symptoms I was having, nobody explained anything to me," said Nixon.
Finding out exactly what did happen took Nixon and her family through a maze of bureaucracy within the Vancouver Island Health Authority. And while Nixon navigated her way in and out of that labyrinth, she now wants others to pick up the thread she has left in the name of patient safety.
"We never faulted the medical professionals for the adverse event that I experienced," she said. "It is my belief that when an adverse event occurs, the patient and their family are entitled to full disclosure of the details so that they can make informed decisions about their immediate, ongoing and future care."
Several weeks after Nixon went home to recover, a comment from a nurse triggered her initial curiosity.
"She was the first person to tell me that I was a walking miracle. Nobody had ever explained my complications to me. I began wondering what had happened."
In March 2007 she returned to work, and decided to get all her medical records from the Vancouver Island Health Authority. She asked for "all medical reports and investigations, notes, consent releases and any other documents related to my care not specifically mentioned in this request."
When she received a pile of paper about an inch thick, Nixon knew there was much more.
"(In hospital) I had two binders, they always had to take them with me wherever I went," she said. "I knew this couldn't be everything."
Though VIHA later insisted the first disclosure included everything, they later told Nixon that due to a staff shortage they were unable to find and process everything related to her care. She recalls how she was told the package was too large to be mailed. It arrived at the end of April 2006.
"Then I started really wondering what happened to me," she said.
A shocked Nixon began to realize that her condition while in ICU was nearly fatal; something that neither she nor her husband were told, despite asking at various times for details about her condition.
"Then I started to realize the magnitude of what happened."
Her concern turned to other medical professionals who later treated her, who would have also been unaware of the exact nature or cause of her ill health. Without that crucial knowledge, said Nixon, her care was jeopardized, and other doctors and nurses put at risk of compounding the original error.
"Many of these medical professionals knew an adverse event had occurred, but allowed me to get well without knowing what happened," said Nixon.
Nixon also wanted to obtain VIHA's consent policy, and that request resulted in her getting a call from health authority's director of risk management. Nixon was given his name, and though she did not ask him to call, he phoned a few days later and left a message.
"I had no idea why he would be calling me. I was very concerned."
She later returned his call, and her concern increased still more.
"He said he'd personally read all my charts," she said.
He then offered to meet her and her husband in person, and he met them at their Parksville home on April 19.
"He arrived thinking he was going to speak to us about informed consent," said Nixon.
Instead she presented him with a banker's box filled with her medical records related to the June 2005 surgical error. During the five-hour meeting, Nixon and her husband made it very clear they wanted one thing to emerge from the investigation into their seven complaints and 34 concerns: To uncover details so that her experience can be used to instruct others about handling adverse events.
"I think something good can come out of this one medical experience, a lot of people can learn from it," she said. "I want them to be educated on how to react when an adverse event occurs."
Nixon made it clear that she had no intention of suing VIHA, but only wanted to find out what happened to her.
In the months and weeks that followed that meeting, Nixon got no letter acknowledging her complaint, no follow ups or information on the investigation.
"The replies I received were vague, I was not informed about how my complaint was being handled or who was handling it."
She asked who was doing the investigation and was told it was a consultant whom she never talked with. She was also never told who it was or given their qualifications. Nixon also tried to determine if the investigation was being done under section 51 of the Evidence Act. She was told at one point it was not, but that the investigation was a "review of systems."
When the risk manager called her in August to report the findings, Nixon exploded. He said the investigation -- under section 51 of the Evidence Act -- didn't find any evidence of negligence. But Nixon never alleged or mentioned negligence in her complaint.
"Do you mean to tell me you've spent four months investigating something I wasn't even complaining about?" she yelled.
"I was devastated to know they'd spent all this time investigating something I never complained about."
In the days following she and her husband asked for a written acknowledgement of that finding. They also asked for VIHA's complaint guidelines, and a root cause analysis study. Neither was sent.
Deeply disappointed, Nixon wanted to go to the top and tried to reach VIHA CEO Howard Waldner, without success. She did meet with senior executives from VIHA, and she left the meeting still feeling frustrated they still didn't understand her objective: "I have provided you (VIHA) a case study, and I've done all the work for you."
She said: "I feel they really do want to make a difference, but the system is broken. Where do you start to fix something that is so broken?"
But Nixon said a patient safety movement is on and hopes VIHA will find a meaningful way to include patients in a new patient safety process.
With her experience of feeling failed by medical professionals and VIHA, Nixon is now convinced that patients must now work for their own rights.
She is healthy now, and VIHA admits that Nixon's experience leaves room for improvement. But they appear to show no interest in working with her as they seek to further patient safety.
They are willing to offer her a formal apology, but show no interest in assisting Nixon as she considers establishing a patient safety foundation.
PWalton@nanaimodailynews.com
250-729-4230
***************************************
The Daily News (Nanaimo) Thursday, November 29, 2007
VIHA Investigation
A report from the Vancouver Island Health Authority "relating to the medical care and treatments of Mrs. Rhonda Nixon" recommends a formal apology.
The report also concludes that communication between medical staff at NRGH was inadequate, "leading to distrust and lack of confidence on the part of the (Nixon) family," states the report, prepared by Lesely Moss, executive director of quality and patient safety.
"There are multiple care concerns that occurred during RN's hospitalization that were less than satisfactory and effective communication surrounding these events did not occur," stated Moss.
She also concluded that the investigation was poorly handled.
DOCS NOT REPORTING ERRORS/DISCLOSURE PROGRAM CAN HELP
Below is a news article that has made its way around the Internet: Docs generally don't report errors or colleagues who make errors. It's a familiar story; however, a disclosure program can change this situation for the better. Disclosure changes the culture of a hospital or medical practice. People are encouraged to report adverse events, and all staff members feel more empowered. Medical errors are eventually seen as golden learning opportunities with a robust disclosure program. Bottom line, disclosure improves medical care and reduces errors by encouraging people to report and talk about events. Hopefully the article below will eventually be a thing of the past.
Almost 50 Percent of U.S. Doctors Keep the Lid Shut on Incompetence
by Daisy Sarma
December 4, 2007
The Money Times
A new report by researchers uncovered an alarming trend: nearly half of all doctors in the United States failed to report a colleague who was incompetent or even unethical. The doctors surveyed during the course of the study, however, agreed such mistakes and practices should be reported.
Published in the Annals of Internal Medicine, the report showed of the total number of doctors who were part of the study, 46 percent knew of at least one serious medical error on the part of a colleague. None of this 46 percent, however, reported the error to the authorities.
The leader of the study was Eric Campbell from the Massachusetts General Hospital and Boston's Harvard Medical School. Campbell and his team surveyed a total of 1,600 doctors during 2003 and 2004 for their report.
The study showed close to 96 percent of the doctors surveyed said all cases of ‘significant incompetence’ or medical errors should be reported to the hospital clinic or the medical authorities. Among cardiologists and surgeons, this number was substantially lesser at 45 percent.
Also, 85 percent of the doctors surveyed said patients or their relatives needed to know about any significant errors on the part of the doctor treating the patient. Unfortunately, most of this was just what the doctors believed should be done. According to Campbell, there was a big gap between what the doctors admitted to knowing was the right thing to do and actually doing it.
The study came up with some other startling facts. For instance, it showed a number of doctors did not mind subjecting a patient to mostly unnecessary and sometimes expensive test procedures, such as MRI scans. The number of doctors who said they tried to ensure they did not unintentionally treat a patient differently from others on account of race or sex stood at 25 percent.
At least 40 percent of the doctors surveyed said they knew about some serious medical error occurring in their practice or hospital, and 31 percent admitted they had not done anything about it at least once. Other alarming trends also came to the fore. For instance, while 93 percent of the doctors surveyed said patients deserved care irrespective of whether they could pay, only 69 percent actually treated patients without insurance.
The number of doctors who have subjected themselves to a competency review over the past three years stands at a mere 31 percent. All of this information assumes vital significance in the light of a report by the U.S. Institute of Medicine in 2000 that said 98,000 Americans die every year solely because of medical errors in hospitals.
So what prevents medical boards from going after erring doctors? Dr. James Thompson, CEO of the Federation of State Medical Boards, says state medical boards face limitations when it comes to punishing physicians. He also said one reason why doctors did not report erring colleagues was because they were aware not much could be done about making them more competent.
Dr. Thompson said other problems included the fact that many of the state medical boards were understaffed and did not receive adequate funding. He said there were certain state medical boards that did not even have their own investigating team. Finally, Dr. Thompson said no state board could take action unless someone reported an erring doctor, which threw the ball back in the court of the doctors.
Regardless of who needs to do something about it, the fact remains that something needs to be done fast about unethical and incompetent doctors; otherwise more Americans will continue to die at hospitals because of medical errors.
- Military week for Sorry Works!
- Canadian Article on Disclosure
- Docs not reporting errors/disclosure program can help
MILITARY WEEK FOR SORRY WORKS!
This was military week for Sorry Works!
Doug Wojcieszak, SW! founder and spokesperson, delivered two speeches on disclosure and apology to Womack Army Hospital at Ft. Bragg North Carolina and the Dorn Veterans Administration Medical Center in Columbia, SC. Both presentations were well-received. It was exciting to make these presentations since the disclosure movement was started at the VA Medical Center in Lexington, Kentucky and the Sorry Works! e-newsletter has numerous military subscribers. Our troops deserve the best, including the whole truth after adverse medical events. They deserve answers and fixes and it's encouraging to see the progress we are making in the military's medical community.
If you are interested in a Sorry Works! presentation, e-mail doug@sorryworks.net or call 618-559-8168.
CANADIAN ARTICLE ON DISCLOSURE
Below is an article on lack of disclosure involving a patient in the Canadian healthcare system. Though the Canadian healthcare system has many differences with American healthcare, the story below and the cultural issues covered are a match with American healthcare. Sorry Works! has many supporters in Canada, and disclosure is a hot topic north of the border, but as the article illustrates we still have a long way to go...north and south of the border.
The Daily News (Nanaimo)
Thursday, November 29, 2007
'Routine' surgery causes injury; A Parksville woman demanded answers, and was shocked at what she found
By Paul Walton
There is no such thing as "minor," "routine" or "risk-free" surgery. Ask Rhonda Nixon. In June, the Parksville woman went into Nanaimo Regional General Hospital for a surgical procedure that -- if it went well -- would have her back on her feet with little inconvenience. But it didn't go well. Nixon, 41 years old and with two teenage boys, ended up in the NRGH intensive care unit for 10 days, and it was another 20 days before she left the hospital.
It was a year before Nixon was well enough to return to work. And it was only then that she learned details about what went wrong in her surgery. Medical staff admitted to what in medical jargon is an "adverse event" -- some even saying they were "sick about what happened" -- but little more.
It would be nearly a year before she learned they had perforated a bile duct, considered one of the worst complications arising from the type of procedure Nixon underwent.
"Nobody ever explained it to me, in the hospital or out of the hospital, the symptoms I was having, nobody explained anything to me," said Nixon.
Finding out exactly what did happen took Nixon and her family through a maze of bureaucracy within the Vancouver Island Health Authority. And while Nixon navigated her way in and out of that labyrinth, she now wants others to pick up the thread she has left in the name of patient safety.
"We never faulted the medical professionals for the adverse event that I experienced," she said. "It is my belief that when an adverse event occurs, the patient and their family are entitled to full disclosure of the details so that they can make informed decisions about their immediate, ongoing and future care."
Several weeks after Nixon went home to recover, a comment from a nurse triggered her initial curiosity.
"She was the first person to tell me that I was a walking miracle. Nobody had ever explained my complications to me. I began wondering what had happened."
In March 2007 she returned to work, and decided to get all her medical records from the Vancouver Island Health Authority. She asked for "all medical reports and investigations, notes, consent releases and any other documents related to my care not specifically mentioned in this request."
When she received a pile of paper about an inch thick, Nixon knew there was much more.
"(In hospital) I had two binders, they always had to take them with me wherever I went," she said. "I knew this couldn't be everything."
Though VIHA later insisted the first disclosure included everything, they later told Nixon that due to a staff shortage they were unable to find and process everything related to her care. She recalls how she was told the package was too large to be mailed. It arrived at the end of April 2006.
"Then I started really wondering what happened to me," she said.
A shocked Nixon began to realize that her condition while in ICU was nearly fatal; something that neither she nor her husband were told, despite asking at various times for details about her condition.
"Then I started to realize the magnitude of what happened."
Her concern turned to other medical professionals who later treated her, who would have also been unaware of the exact nature or cause of her ill health. Without that crucial knowledge, said Nixon, her care was jeopardized, and other doctors and nurses put at risk of compounding the original error.
"Many of these medical professionals knew an adverse event had occurred, but allowed me to get well without knowing what happened," said Nixon.
Nixon also wanted to obtain VIHA's consent policy, and that request resulted in her getting a call from health authority's director of risk management. Nixon was given his name, and though she did not ask him to call, he phoned a few days later and left a message.
"I had no idea why he would be calling me. I was very concerned."
She later returned his call, and her concern increased still more.
"He said he'd personally read all my charts," she said.
He then offered to meet her and her husband in person, and he met them at their Parksville home on April 19.
"He arrived thinking he was going to speak to us about informed consent," said Nixon.
Instead she presented him with a banker's box filled with her medical records related to the June 2005 surgical error. During the five-hour meeting, Nixon and her husband made it very clear they wanted one thing to emerge from the investigation into their seven complaints and 34 concerns: To uncover details so that her experience can be used to instruct others about handling adverse events.
"I think something good can come out of this one medical experience, a lot of people can learn from it," she said. "I want them to be educated on how to react when an adverse event occurs."
Nixon made it clear that she had no intention of suing VIHA, but only wanted to find out what happened to her.
In the months and weeks that followed that meeting, Nixon got no letter acknowledging her complaint, no follow ups or information on the investigation.
"The replies I received were vague, I was not informed about how my complaint was being handled or who was handling it."
She asked who was doing the investigation and was told it was a consultant whom she never talked with. She was also never told who it was or given their qualifications. Nixon also tried to determine if the investigation was being done under section 51 of the Evidence Act. She was told at one point it was not, but that the investigation was a "review of systems."
When the risk manager called her in August to report the findings, Nixon exploded. He said the investigation -- under section 51 of the Evidence Act -- didn't find any evidence of negligence. But Nixon never alleged or mentioned negligence in her complaint.
"Do you mean to tell me you've spent four months investigating something I wasn't even complaining about?" she yelled.
"I was devastated to know they'd spent all this time investigating something I never complained about."
In the days following she and her husband asked for a written acknowledgement of that finding. They also asked for VIHA's complaint guidelines, and a root cause analysis study. Neither was sent.
Deeply disappointed, Nixon wanted to go to the top and tried to reach VIHA CEO Howard Waldner, without success. She did meet with senior executives from VIHA, and she left the meeting still feeling frustrated they still didn't understand her objective: "I have provided you (VIHA) a case study, and I've done all the work for you."
She said: "I feel they really do want to make a difference, but the system is broken. Where do you start to fix something that is so broken?"
But Nixon said a patient safety movement is on and hopes VIHA will find a meaningful way to include patients in a new patient safety process.
With her experience of feeling failed by medical professionals and VIHA, Nixon is now convinced that patients must now work for their own rights.
She is healthy now, and VIHA admits that Nixon's experience leaves room for improvement. But they appear to show no interest in working with her as they seek to further patient safety.
They are willing to offer her a formal apology, but show no interest in assisting Nixon as she considers establishing a patient safety foundation.
PWalton@nanaimodailynews.com
250-729-4230
***************************************
The Daily News (Nanaimo) Thursday, November 29, 2007
VIHA Investigation
A report from the Vancouver Island Health Authority "relating to the medical care and treatments of Mrs. Rhonda Nixon" recommends a formal apology.
The report also concludes that communication between medical staff at NRGH was inadequate, "leading to distrust and lack of confidence on the part of the (Nixon) family," states the report, prepared by Lesely Moss, executive director of quality and patient safety.
"There are multiple care concerns that occurred during RN's hospitalization that were less than satisfactory and effective communication surrounding these events did not occur," stated Moss.
She also concluded that the investigation was poorly handled.
DOCS NOT REPORTING ERRORS/DISCLOSURE PROGRAM CAN HELP
Below is a news article that has made its way around the Internet: Docs generally don't report errors or colleagues who make errors. It's a familiar story; however, a disclosure program can change this situation for the better. Disclosure changes the culture of a hospital or medical practice. People are encouraged to report adverse events, and all staff members feel more empowered. Medical errors are eventually seen as golden learning opportunities with a robust disclosure program. Bottom line, disclosure improves medical care and reduces errors by encouraging people to report and talk about events. Hopefully the article below will eventually be a thing of the past.
Almost 50 Percent of U.S. Doctors Keep the Lid Shut on Incompetence
by Daisy Sarma
December 4, 2007
The Money Times
A new report by researchers uncovered an alarming trend: nearly half of all doctors in the United States failed to report a colleague who was incompetent or even unethical. The doctors surveyed during the course of the study, however, agreed such mistakes and practices should be reported.
Published in the Annals of Internal Medicine, the report showed of the total number of doctors who were part of the study, 46 percent knew of at least one serious medical error on the part of a colleague. None of this 46 percent, however, reported the error to the authorities.
The leader of the study was Eric Campbell from the Massachusetts General Hospital and Boston's Harvard Medical School. Campbell and his team surveyed a total of 1,600 doctors during 2003 and 2004 for their report.
The study showed close to 96 percent of the doctors surveyed said all cases of ‘significant incompetence’ or medical errors should be reported to the hospital clinic or the medical authorities. Among cardiologists and surgeons, this number was substantially lesser at 45 percent.
Also, 85 percent of the doctors surveyed said patients or their relatives needed to know about any significant errors on the part of the doctor treating the patient. Unfortunately, most of this was just what the doctors believed should be done. According to Campbell, there was a big gap between what the doctors admitted to knowing was the right thing to do and actually doing it.
The study came up with some other startling facts. For instance, it showed a number of doctors did not mind subjecting a patient to mostly unnecessary and sometimes expensive test procedures, such as MRI scans. The number of doctors who said they tried to ensure they did not unintentionally treat a patient differently from others on account of race or sex stood at 25 percent.
At least 40 percent of the doctors surveyed said they knew about some serious medical error occurring in their practice or hospital, and 31 percent admitted they had not done anything about it at least once. Other alarming trends also came to the fore. For instance, while 93 percent of the doctors surveyed said patients deserved care irrespective of whether they could pay, only 69 percent actually treated patients without insurance.
The number of doctors who have subjected themselves to a competency review over the past three years stands at a mere 31 percent. All of this information assumes vital significance in the light of a report by the U.S. Institute of Medicine in 2000 that said 98,000 Americans die every year solely because of medical errors in hospitals.
So what prevents medical boards from going after erring doctors? Dr. James Thompson, CEO of the Federation of State Medical Boards, says state medical boards face limitations when it comes to punishing physicians. He also said one reason why doctors did not report erring colleagues was because they were aware not much could be done about making them more competent.
Dr. Thompson said other problems included the fact that many of the state medical boards were understaffed and did not receive adequate funding. He said there were certain state medical boards that did not even have their own investigating team. Finally, Dr. Thompson said no state board could take action unless someone reported an erring doctor, which threw the ball back in the court of the doctors.
Regardless of who needs to do something about it, the fact remains that something needs to be done fast about unethical and incompetent doctors; otherwise more Americans will continue to die at hospitals because of medical errors.
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