I would imagine that Jan is probably a committee member of the
National Patient Safety Foundation (http://www.npsf.org). She must be
at least an ordinary member of the organisation, otherwise her
constant calls for someone to do something about patient safety could
be seen as hypocrisy.

As I have told her before, I paid my money to be a member of my local
organisation (http://www.apsf.net.au) addressing the problem of
patient safety (I posted my membership renewal cheque today). What has
she done except whinge?

Also, I have just sent off my payment to Health Skepticism
(http://healthyskepticism.org) which has the aim of "Improving health
by reducing harm from misleading drug promotion".

*I* did.

<snip diversions>

http://www.newsinferno.com/storypages/8-02-2005~003.html

President Signs Law Creating National Database on Medical Errors - Critics
Believe Under-Reporting Will Continue
Date Published: August 2, 2005
Source: Newsinferno.com News Staff

In an effort to reduce medical errors and improve safety, President Bush
signed into law bill S 544 creating a national patient safety database.

The intent of the legislation is to encourage health care providers to
report errors to safety organizations which can analyze trends and create
proposals to help prevent similar mistakes from occurring in the future.

The data which will be available will not identify specific patients, health
care providers, or individuals who report problems and it cannot be used
against providers as evidence in malpractice suits, other litigation, or by
accrediting bodies or regulators.

The President stated that " by providing doctors with information about what
treatments work and what treatments cause problems, we will reduce medical
errors that injure and cause the deaths of thousands of Americans each
year."

Reaction to the legislation, which passed the Senate on July 21 and the
House on July 27, was mixed. For example, J. Edward Hill, president of the
American Medical Association , said the law is "the catalyst we need to
transform the current culture of blame and punishment into one of open
communication and prevention."

Dr. Hill added, "Future errors can be avoided as we learn from past
mistakes. This law strikes the proper balance between confidentiality and
the need to ensure responsibility throughout the health care system."

Critics, however, argued that the law should have included federal penalties
for medical errors and that it does not guarantee that providers will report
mistakes.

Margaret Van Amringe, vice president for public policy and government
relations for the Joint Commission on Accreditation of Healthcare
Organizations ( JCAHO), said "There's no incentive to report useful
information if you know it is going to be used against you. If you don't
have the information then you are not going to solve the problem."

To further address these concerns JCAHO said it might be one of the groups
responsible creating a subsidiary "patient safety organization."

Reporting of errors has always been a serious problem within the medical
community. There are several reasons for this including: (1) exposure to
civil liability; (2) exposure to governmental sanctions and penalties; (3)
licensing problems associated with most documented errors; (4) loss of
revenue and/or reputation especially with respect to hospitals or other
medical facilities.

In January of 2003, the National Practitioner Data Bank (NPDB) reported that
just 5% of U.S. doctors are responsible for 54% of all malpractice. Yet even
after a doctor has been found liable for malpractice, there is no guarantee
that he or she will be penalized in any way with respect to practicing
medicine.

In fact, only a small percentage of the worst doctors have their licenses
suspended and even fewer have their licenses revoked. The rest are either
shifted around (similar to the way in which priests who were known to have
abused children were simply transferred to other parishes) or move to
another community in the same or another state.

In any event, such "problem" doctors have no difficulty in continuing to
practice medicine. Doctors have even been known to move to other countries
in order to continue practicing medicine when their ability to do so in the
United States has been compromised as a result of extremely serious
infractions.

It is well known in the medical profession itself that doctors are not
always inclined to report their errors, or those of their colleagues, for a
number of reasons. These include: (a) the desire to escape punishment; (b)
the unwillingness to admit their negligence; (c) the belief that protecting
a colleague will somehow ensure the same degree of loyalty from that person
when and if the tables are turned; (d) fear of retribution from one or more
superiors; (e) a reluctance to bring one's hospital into disrepute; and (f)
sheer arrogance.

This routine lack of accountability for medical errors is the main reason
why they remain so prevalent and continue to be a threat throughout this
country and the world.

In 2001, the JCAHO announced certain standards for medical practice in
hospitals in the United States including working actively to prevent medical
errors, designing patient safety systems, and encouraging and acting on
internal reports of errors. Creating a standard and actually having doctors
follow it are two entirely different matters, however.

In the last decade, 84% of Health Maintenance Organizations (HMOs) and 60%
of hospitals failed to report medical errors to the government, allowing
many health care professionals to literally get away with murder. Many
experts see this disregard of reporting requirements as being as close to
having a "license to kill" as you can come without being James Bond.

Consider the recent case of Charles Cullen, a registered nurse who may have
killed as many as 40 patients at 10 hospitals in New Jersey and Pennsylvania
over the course of 16 years.

Although Mr. Cullen was investigated on a number of occasions with respect
to misusing potentially lethal drugs and was fired or allowed to resign from
a number of hospitals, he was permitted to "hopscotch" from hospital to
hospital without the slightest difficulty.

The penalty for failing to report errors may include the removal of legal
protections from the government, yet this penalty is rarely imposed. While
information on incompetent doctors is supposed to be listed in the NPDB,
oftentimes reportable incidents fail to make it any further than the
hospital they occurred at.

The doctors involved are simply given a slap on the wrist and then permitted
to return to their duties. A new debate has arisen as to whether the
information on the NPDB should be available to the public. Of course doctors
are strongly opposed to such an idea, claiming that once a malpractice claim
is filed, their record will be tainted even if that claim is unsuccessful.

In New York, for example, the Department of Health (DOH) has been criticized
for failing to revoke medical licenses in appropriate situations. One cause
of this, however, may be the fact that New York City hospitals have been
repeatedly cited as being the worst in the state for reporting medical
errors, even those resulting in death, to the DOH.

In 2001, the state Commissioner of Health, Dr. Antonia C. Novello, stated:
"People are not unemployable just because they have made a mistake, but when
you break the trust of the public good, I don't think you should be able to
practice." Yet doctors who have made mistake after mistake are still
practicing and still making preventable medical errors. In fact, more than
75% of doctors who were disciplined in the past 8 years began working again
after they were punished by the state.

What is missing here is a clear and concise plan explaining how hospitals
should handle problematic doctors and preventable medical errors. Also
missing is a uniform system which provides information on previously
disciplined medical professionals so that subsequent employers are aware of
their past record.

Such a system would have saved many patients from being killed by Charles
Cullen in New Jersey and Pennsylvania between 1987 and 2003.

As is often the case, money is also part of the problem. Simply stated, no
medical facility wants to get rid of a good earner and, as luck would have
it, doctors with disciplinary problems are often among the top third of
moneymakers at their given hospitals.

Doctors who are consistent and plentiful income producers are often praised
for their ability to provide a constant patient stream to the hospital while
actually avoiding punishment for any questionable practices resulting in
preventable medical errors.

In this regard, consider the chilling situation that occurred at Redding
Medical Center in California. One particular cardiologist was
single-handedly responsible for making his small, rural hospital one of the
most lucrative business enterprises for its owner, Tenet Healthcare.

Unfortunately, the doctor was only able to do this by intentionally making
false diagnoses of heart-related problems in order to justify performing
hundreds, if not thousands, of unnecessary procedures and surgeries.

While other staff members were suspicious of the goings on at the hospital,
their concerns were dismissed by their superiors until the scheme was
exposed by one patient, a 55-year-old reverend, who sought a second opinion
after he was told he needed emergency triple bypass surgery.

A highly qualified cardiologist was shocked by the diagnosis and told the
patient that his heart was in perfect shape. Federal agents raided the
hospital and Tenet was eventually forced to pay $54 million in penalties for
the unnecessary heart procedures.

This, however, does not change the fact that this single doctor was a staple
at the Redding Medical Center for almost two decades and was being protected
by his superiors who were only concerned with the enormous annual revenue he
produced and not the quality or legitimacy of his practice.

Thus, it remains to be seen if a reporting system without any real teeth
will be able to take a significant bite out of the problem of medical
errors.