ReThinking Patient Safety

What is the Problem: Preventable Deaths and Injuries or the Lawsuits That Follow?

Debates over the civil justice system, i.e. whether we need tort reform to deter so called "frivolous lawsuits," generate much heat, but little light. Tort reform distracts our attention from preventing needless injuries and deaths. The medical community expressed shock by the 1999 Institute of Medicine report estimating the number of Americans killed each year by medical errors between 44,000 and 98,000.Subsequent estimates are 195,000 unnecessary deaths. Recent news reports estimate over 2,000 British citizens killed each year, and a staggering 525,000 injured. 

Why are we not outraged by these numbers? Why don't these deaths and injuries command as much political discussion as so called "frivolous lawsuits?" 

In 2001, a medical error killed a teenager at west coast hospital. After surgery, the teenager received pain relief through a "patient controlled analgesia (PCA) pump." Unfortunately, the pump delivered too much pain medicine. The surgery was a complete success, but the patient died. The child's death devastated not only the family, but the hospital as well. How could this have happened there? 

To its credit, the hospital publicly took responsibility for the error. It conducted a thorough investigation. A meeting was held, publicly discussing the incident and the investigation. If each medical error received this level of attention, patient safety and tort reform would not be public issues. 

What lessons can we learn from this incident? As a trial lawyer, I had worked on similar PCA pump incidents in 1992 and 1994. My clients agreed to non-disclosure agreements. Could publicity of those two incidents have prevented the 2001 death? 

Reviewing the medical literature demonstrated over 75 articles warning of this problem dating back to 1982, twenty years before the 2001 incident. Titles of the articles warn: 

1989: "The Need for Caution," "Safety Hazard," "Severe Respiratory Depression;" 

1991: "Beware.;" 

1992: "Oversedation," "Overdose of Opoid," "Solving the Problems..," "A Survey of Complications," Half of [PCA pumps] Could Cause Mishaps," "A Serious Incident;" 

1993: "Preventing Errors [w PCA pumps]," "A Hidden Risk Throughout the Hospital Environment;" 1994: "Respiratory Depression.. Review of Eight Cases," "Identification of [PCA] Overdoses," "Overdose of Opiate;" 

1995: six articles warning of "Hazard," "Overdose," and "Failure" [w PCA pumps] 

1996: "Respiratory Depression," "Morphine Overdose," "Infusion Confusion;" 

1997: "[PCA pumps] Prone to Misprogramming," "Eliminating Errors," "Human Error," 

1998 - 2001: "Just When We Thought We Understood [PCA]," "Preventing Future Adverse Events," "Anesthesia Equipment and Human Error," and "Patient Uncontrolled Analgesia." 

The Food and Drug Administration has maintained a publicly accessible database for reporting of adverse incidents associated with various medical devices. The standards for reporting these incidents have evolved, but most accept that not all adverse incidents are reported. That database contained over 8,000 reports of over 4,000 incidents involving PCA pumps. What is the problem to be addressed? 

The tort reform community tells us the problem is that the few of these incidents that have resulted in lawsuits and settlements or verdicts are driving up malpractice insurance premiums. They tell us increases in those premiums make it more difficult to receive health care. The few lawsuits arising out of these incidents are the problem. 

There is another view. Why didn't someone pay attention to the first five, ten, fifteen, hundred, or even a thousand incidents before taking action? Why didn't the professional organizations convene a meeting to take steps after even the first hundred or thousand such incidents? How many families were devastated by the death or brain damage of a loved one? Why does it take a lawsuit to call attention to these problems? Errors in programming PCA pumps are merely one kind of medical error. 

Sadly, the hospital did not learn from the many articles in the medical literature that it needed to take steps to prevent these injuries. We as a society failed to make an adequate response to the thousands of reports in the FDA database. That database suggests so many incidents that it seems likely that each of America's 6000 hospitals only paid attention to this problem after an incident occurred on their premises. 

How many types of medical errors are there? Is each type of error repeated at each of America's 6000 hospitals before corrective action is taken? It is sad that the only way citizens have of getting the medical community to pay attention to a problem is to file a lawsuit. 

It is our choice. Is the problem: 

A. The medical errors and resulting injuries and deaths, or 

B. The lawsuits that a few of the victims file? 

That answer will determine whether the appropriate solution is to learn from the lawsuits or eliminate them.

2 of my Favorite Essays - "Marla Ruzicka: The Best There Ever Was" & "In Praise of Role Players"

"Marla Ruzicka: The Best There Ever Was" 

Lee Tilson

(Copyright Lee Tilson 2005)

(Note: After reading of the death of Marla Ruzicka in Baghdad in April 2005, I felt compelled to write this essay.  More information is readily available about this remarkable young woman at the website of the organization she founded   http://www.civicworldwide.org  and Wikipedia.)

 

 

 

 

 

 

 

 

 

 

 

 

     I didn't know Marla Ruzicka. Nevertheless I am compelled to read what I can find about her, and to write to understand. Each glowing tribute leaves something important unsaid.  Last night, while watching the Robert Redford and Glenn Close movie, The Natural, another insight became clear.

     The stories about Marla describe how easily and strongly she connected with everyone: Afghans and Iraqis, conservatives and liberals, children and adults, injured civilians and soldiers, journalists and politicians. The tributes come from those she helped, everyone she encountered, and some like myself who read about her. She has earned the praise of childhood friends and senior statesmen, photographers and ambassadors, decorated veterans and pacifists, lawyers and retirees.

     Speeches portray Marla as having the determination of an Olympic athlete, the wisdom of an experienced businessman, the impish playfulness of a teenage babysitter, the instincts of a seasoned politician, a cheerleader's good looks, and the empathy of Mother Theresa. These talents were focused on persuading America to keep faith with its fundamental values by accepting responsibility for children and innocent civilians (non-combatants) injured in war.

     Journalist Steve Cooper claims Marla breathed life back into a horribly injured child he had judged to be among the "living dead." The Iraqi Ambassador to the UN thanked Marla's family for her sacrifice. Soldiers appreciated Marla's having taught them to see beauty in Baghdad and helping them do their jobs. Reporter Peter Bergen reminded us that no man can have a greater love than to lay down his life for his fellow man. Afghan American Masuda Sultan counted thousands of Afghans thatMarla helped. Kevin Kellems, former spokesperson for Vice President Cheney, Secretary Rumsfeld and Paul Wolfowitz, praisedMarla as a unifier and a gift to her age. An eloquent post by Lance Etchison mentions how much Marla enjoyed discussing fashion with him. UPI reporter Shaun Waterman wanted Marla to teach his son to rollerblade. On one of the CIVIC videos,Marla blows on a laughing child's tummy to make an unintelligible noise. Marla's magic touched the soul of everyone she met.

     Consider the lessons we try to teach our children: be yourself, follow your heart, do the right thing. Marla practiced them. In Plato's dialogues, Socrates teaches the sophists lessons about virtue. Marla knew them. Immanuel Kant instructs us to treat everyone as an end in herself and not as a means, and to act on universal maxims. Marla lived them.

     Marla's accomplishments are enormous. She saved lives. She renewed hope in thousands of people living in devastated communities. She persuaded the most powerful military machine, the most powerful democracy in the history of the world, to admit that it had done something wrong that needed correction. It had injured innocent people. The victims deserved compensation. She was featured on CNN and Nightline at age 26. She was feted in major newspapers and magazines. She died at 28. How can we appreciate what she achieved in her short life? What can be accomplished by age 28?

     Most of our successes by age 28 are rather ordinary. Other than actors, rock stars and athletes, few are celebrated for accomplishments by age 28. To whom can we compare Marla?

     At age 26, Martin Luther King, Jr., received his Ph.D., and had begun working on the Montgomery Bus Boycott. Albert Einstein had just begun writing. At age 27, Isaac Newton was appointed chair of mathematics at Trinity. Their major successes would come in later decades of their lives.

     While 28, Gandhi and his family suffered one attack in South Africa, Abraham Lincoln was admitted to the practice of law in Illinois, and George Washington served as an aide to British General Braddock. At 29, John Kennedy was elected to Congress. Mother Theresa took her final vows as a nun at 27, went to Calcutta at age 37, and founded her order at age 40.

     By 28, Marla achieved more: she had persuaded the most powerful empire in history to recognize and take responsibility for mistakes, grievous mistakes.

     Must we really look as far back as Joan of Arc and Alexander the Great to find anyone with comparable impact? (Unlike Joan and Alexander, Marla had no weapons, no army.)

     At the end of The Natural, Glenn Close consoles Robert Redford about his past choices with her belief that we get two lives: "one to learn with, and one to live with." Robert Redford says that he wants to be known as "the best there ever was."

     Marla Ruzicka didn't need a life for learning, she already knew. She knew who she was. She knew how to love. She knew how to connect with anyone and everyone. She knew how to do the right thing. She knew how to speak truth so that power would listen.

     Perhaps Marla is speaking to us, asking that we use her life as the one with which to learn. Might she be asking us to use the rest of our lives as she did: loving children, caring for the injured, admitting mistakes, wearing the clothes we want and keeping the friends we want, rollerblading where we want, following our hearts and doing the right thing?

     We can study how Marla chose to live, the lives she renewed, the injured she healed, the hearts she touched, the friends she inspired, or what she accomplished. By any measure and in comparison to any standard, it can be said:

     "That was Marla Ruzicka. She was the best there ever was."

Lee Tilson

 

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In Praise of Role Players

by Lee Tilson

(Copyright Lee Tilson 1997)

http://tinyurl.com/In-Praise-Of-Role-Pla

 

As a guitar hobbyist from the sixties, I often think about the secret for making a great band. If I knew the formula, I could be in a great band. What are the ingredients? How should they be blended? Why were my favorite bands, the Beatles and Booker T and the MG’s (henceforth: BTMGs) so good? (Note: Booker T and the MG’s was the house band for Stax Records in Memphis, backing up numerous soul acts including Otis Redding, Sam and Dave, and Wilson Pickett. They were the consensus “house band” for the opening ceremonies at the Rock and Roll Hall of Fame.) How did these bands manage to endure? What can we learn from their examples?

 

Perhaps we can learn a lot. Maybe we can learn why some groups achieve far more than the combined achievements of their members. Possibly, there are lessons about how to build teams.

 

I focus on these groups for two reasons. First, they were true bands, not vehicles for an outstanding soloist (e.g. the Jimi Hendrix Experience, or B.B. King’s band). They functioned as units. Second, the groups revolutionized popular music. Third, the groups endured and evolved. While some bands developed a “sound” repeated on most of their records (the Byrds, the Beach Boys), the Beatles (compare “Please, Please Me” to “A Day in the Life”) and Booker T and the MG’s (compare “Green Onions” to “The Way It Should Be”) evolved.

 

Three facts about the two groups stand out. First, each of the parts played by the musicians seemed easy to play. Musicians in the audience thought, “That’s not so hard. I could play that.” Each part was simple. There were no dazzling solos. Second, every note supported the song’s theme. Nothing was extraneous. Solos enhanced the feel of the song, rather than display the artistic genius of the soloist. Third, the band members liked and respected each other. One of the most poignant comments in the recent “Anthology” videotape of the Beatles belongs to Ringo: “We were four guys who really loved each other.. .1 had the three greatest brothers in the world.”

 

These bands followed the formula of the great sports teams.

 

On a flight several years ago, I was fortunate to be seated next to McCoy McLemore, forward for the 1970-71 world champion Milwaukee Bucks. He has made a career giving speeches about teamwork. As he told me his story, he was offered a chance to play for the Milwaukee Bucks when they were building a championship team. He was asked whether he was willing to execute the role of number 78 in the playbook. He was upset to see that number 78 had exactly two plays in the book: inbounding the ball, and standing in the corner. The team told him that they needed someone for those two plays. If he was willing to be number 78, he would be on a championship team. If he was not willing to be number 78, he would be traded. He agreed to be number 78. He now wears a championship ring.

 

Other great sports teams, the Bill Russell Celtics, the Lombardi Packers, the John Wooden UCLA Bruins, share this common thread: they are built on role players. Everyone on the team plays a special albeit limited role. Each player performs a role. As a group of role players, each team member can feel special. Egos are kept in check.

 

Remember the recent Pistons champions? Players had nicknames describing their roles. Vinnie Johnson was “the Microwave” because he heated up the game scoring off the bench. Dennis Rodman, the “Worm,” squirmed his way inside for rebounding position. Isaiah Thomas was “the Captain,” the dependable leader. Bill Laimbeer and Rick Mahorn were the intimidating “bad boys” who played physical defense in the paint. Role players. Their nicknames reinforced the very glue that held the team together.

 

Our little music festival similarly relies on role. We all see and appreciate the fine artists who grace our stages. We thank them, and we should. But let us not forget the many willing role players who make the festival possible. We couldn’t have the festival without the stagehands, ticket sellers, and soda handlers. Everyone working today is a volunteer. Thank them. Tell them you appreciate their efforts. 

 

First and foremost, let me thank Brent Spoelstra, who for five years has erected and removed the fence. Without the fence, we could not charge admission, and could not hold the festival. Year after year we have been able to rely on days of Brent’s labor in exchange for nothing more that a verbal “Thanks.” Let’s make sure he hears it.

 

Angela Petroff returns for her third festival this year. She has recruited, organized and run the children’s activities for us. This year, she agreed to assemble this program book. She has no connection to the school. She cares about kids and the arts. Our community is fortunate to include her.

 

Anneliese Failla recruited our first vendors, and has organized the front gate for three years. She works for the Philo law firm, and lacks a connection to the school. Her efforts here are only one of many ways she expresses her concern for the city.

 

Last year, when our arrangements for beverages fell through, Debbie McGinnis said: “Don’t worry, I’ll take care of it.” And she did. She bought the soda, loaded it into her car, unloaded it at the festival, sold it, and returned the unsold cans to the store. Instead of enjoying the festival, she sat in the hot sun all day so everyone else could have something to drink. She listened to the complaints about the price of the soda  coming from patrons who did not understand that we use soda revenues to pay for the bandshells and microphones. She worked all year developing inroads with the Detroit Public Schools, and arranged for financial contributions and musicians to appear.

 

Gerald Wahl used his many connections with the downtown legal community to solicit monies, musical acts, advisory board members, and community contacts for the festival. Ann Wells did the dirty work of fundraising and selling tickets. Pat Hall lined up musical acts, including our very own Friends School in Detroit Vocal Ensemble which she directs. She established many contacts with other professional musicians. Lafayette Pavillion’s Kathy Wilson lined up Martha Reeves and put us in touch with SNAP, the Lafayette Park community association, which is offering children’s activities and serves our neighborhood so well.

 

Bill Ward worked with his students to develop the T-shirt logo, arranged for the sound systems and the piano. He solicited ads. He sold tickets and T-shirts. Cynthia Reynolds arranged for the Hartford Memorial Baptist Church’s Cherubic Choir to perform, and for significant publicity in the religious community Colleen Robar of Cram’s solicited monies and managed our publicity.

 

Andrea Dickerson established numerous contacts with key community organizations, and, with Pat Hall, arranged for Greenfield Village to send their games to the festival.

 

Darra Ososki, a talented and devoted lawyer who gives much of her time to advocacy for children, returns to manage our Marketplace. She located the vendors, contacted the Smithsonian, talked to the musicians, and even came to school to sell T-shirts and tickets, and she has no connection to the school.

 

Celeste Lee, who feeds children at the school every day, has agreed to operate our food concession. She also obtained our city permits this year, a key task previously performed by Mitchelene Bush. Keith Williams will operate our instrument recycling program in collaboration with the Tatum Foundation for the Arts. Frank Callis has assisted in establishing numerous community contacts and writing articles for the program book. Joan Bodnar arranged for the bandshell, tents, and porta-johns.

 

Let me pay a special tribute to Michael Shane. Mike did it all this year. He raised money from the UAW, lined up key acts (including the Solidarity Singers and Straight Ahead), sold T-shirts and passed out flyers in Eastern Market. Most importantly, Mike kept the committee on track by reminding us of meetings. Mike arranged for the telephone tree which contacted parents at the school. All of us owe a special debt of gratitude to Michael. I know I do.

 Festivalgoers, if you like the festival, do your part. Help me maintain this team of unselfish role players. Thank the volunteers who make this festival possible. Thank the musicians who donate freely of their time, not just to perform, but to practice, to rearrange their schedules, to drive from Lansing, to set aside family obligations and to lend their names and reputations to the festival. Thank our sponsors who paid for ads in our program book. Recognize and appreciate the many role players who worked all year on the festival. Recognize and appreciate that work on previous festivals which made this year’s festival possible: the efforts of Barbara Sale, Kim Hetrick, Curtis Turrentine, Michael Stockdale, and hundreds of others.

 

This essay describes a tiny percentage of the effort which has gone into the festival. I hope I have not offended the dozens of you who worked by failing to mention you. I would feel worse if I mentioned no one. I hope you can feel good about being on the team. I am very proud to be a role player on this team. As a parent, I hope that my work on this festival can help teach my son, by example, of how much can be accomplished by a team of role players.

 

By Lee Tilson

Copyright 1997