THE PATIENT IS DOING WELL!

Linda Kenney's surgery went smoothly yesterday afternoon, and she is resting comfortably this morning in her hospital room. Thank you to everyone for their best wishes and prayers!

OH MY, NOT AGAIN!!!

As many of you know, Linda Kenney, MITSS Executive Director, has a very long history of surgeries on her ankles. Well, she is headed to the hospital today for yet another unexpected surgery. If all goes according to plan, she will be in the hospital for about 3 days with two weeks on crutches after that. She is, of course, very optimistic about her recuperation period and determined not to let this take too much time out of her busy schedule.

Join us in wishing Linda a safe and uneventful surgery as well as a speedy recovery!

TOOLS FOR CONSUMERS AND PRESCRIBERS TO CURB DRUG NAME MIX-UPS

As the Quaid family tragedy illustrates (see post below), prescription drug mix-ups can have devastating consequences. Some drug names in particular are quite similar to others and can lead to confusion for both patients and prescribers. Bad handwriting, smudged ink, or a data entry mistake can change the name of one drug to something altogether different. The results can be dangerous and sometimes lethal. At least 1.5 million Americans are estimated to be harmed each year from medication errors, with name mix-ups accounting for a quarter of them.

The Boston Globe reported in a story on Tuesday that a web-based tool (http://www.usp.org/) is now available to consumers and doctors to check whether they are using or prescribing error-prone drugs and the names they might be confused with. Coming some time this fall from the Institute for Safe Medication Pratices and iGuard (an online health service) is a more patient-oriented website that will send users e-mail alerts about drug-name confusion.

The Food and Drug Administration is also piloting a program that would hold the drug manufacturers more responsible to guard against name confusion. The hope is to avoid confusing drug names before the product gets to market.

The Quaid Family Tragedy

Many of you may have watched 60 Minutes last night. It was a repeat of a story first aired last spring and chronicled the harrowing experience of the Quaid Family (click here for video). Dennis Quaid, the actor, and his wife's newborn twins were accidentally overdosed on Heparin in a California hospital. The babies survived the ordeal, but the Quaids are speaking out about preventable medical errors.

MITSS posted to the 60 Minutes blog last spring, and we'd like to reaffirm our response to the story here:

Our thoughts and prayers go out to the Quaid family. Medical errors and bad outcomes are a huge problem in healthcare demanding urgent attention by hospitals, physicians, nurses, pharmacists, insurers, regulatory agencies, patients and their families, and everyone else involved. We must all work together to come up with effective solutions -- there is far too much at stake. In the interests of balance and fairness, 60 Minutes should have included the many organizations involved in heroic efforts all over the country in terms of prevention. Still, little attention has been paid to the devastating emotional toll taken on patients, family members, and care providers. We are a non-profit organization dedicated to supporting everyone impacted by a bad medical outcome. Even in the safest of systems, things can and do go wrong. Errors occur at a huge financial cost to the system, but let's not ignore the human cost on both sides of the equation.

It wasn't clear from the piece, but it didn't appear that Dennis and his wife were offered any emotional support following their event. Their anger and distress were apparent as it is with anyone who contacts MITSS. Emotional support needs to be "hard wired" into the system when anything goes wrong, for patients as well as clinicians. It's simply the right thing to do.

MASSACHUSETTS GOVERNOR SIGNS COST CONTAINMENT AND QUALITY IMPROVEMENT BILL

Governor Deval Patrick signed S. 2863 (the Cost Containment and Quality Improvement Bill) into law this past Sunday. The purpose of the bill is to help contain the skyrocketing costs of healthcare, while ensuring transparency and continued quality of care for residents of Massachusetts (press release).


Of particular interest to healthcare consumers is that 4 of the 6 quality improvement provisions that our friends on the Consumer Health Quality Council at Health Care for All advocated for were included in the bill and will now be enacted:


1. Public reporting of healthcare-associated infection rates;
2. Public reporting of Serious Reportable Events (or never events) and prohibiting hospitals from being reimbursed for care associated with the events;
3. Requiring hospitals to establish Rapid Response Methods; and,
4. Requiring hospitals to establish Patient and Family Councils.

We'll now have to wait and see what happens with the implementation phase of the bill, but we applaud Governor Patrick's, the Senate's, and the House's leadership on this important piece of legislation.

A GREAT READ AND WONDERFUL WAY TO SUPPORT MITSS!

We highly recommend a new book, The Best Practice, written by former Boston Globe journalist Charles Kenney. The book tells the story of some of the pioneers of the health care quality movement, from Don Berwick to Lucian Leape, who are finding ways to eliminate preventable medical errors and transforming American medicine in the process.


As an added bonus for MITSS, the Institute for Healthcare Improvement (IHI) has generously arranged for 10% of purchases made through a special Amazon.com link to be donated to MITSS. To purchase a copy of The Best Practice through this special arrangement, click here.

Where can you find MITSS this week? The Boston Herald!

This article in the Boston Herald from Sunday 8/3/08 features MITSS founder and Executive Director, Linda Kenney, and one of MITSS’ esteemed board members, Jim Conway. They were asked to comment on the progress and trajectory of apology and disclosure in medicine. Although we are always pleased when this topic is highlighted, it is likely that the column inches allotted were not enough to do it justice. So, we would like to put the question to you: How do you see the progress and direction of apology and disclosure in healthcare? How does it impact you personally?