Progress Slow in Stopping Hospital Harm

MITSS Executive Director, Linda Kenney, is featured on a Channel 5 (WCVB Boston) news story on hospital errors. Included is the compelling story of a nurse harmed at the hospital where she works.

Check out the video at -- http://www.thebostonchannel.com/video/19984320/index.html

Listen In to Rhode Island Public Radio

Rhode Island Public Radio's Megan Hall produced a wonderful piece on the emotional impact of adverse events. It highlights the work that MITSS is doing with patients and families. Tune-in to the link below!

http://www.wrni.org/content/first-do-no-harm-part-3

A Great Resource for Consumers

The Institute for Safe Medication Practices has put together a useful and informative consumer website regarding medication safety. Here is the link:

http://www.consumermedsafety.org

The site has a lot of features like error reporting, safety tools, many safety articles for consumers, etc. The ISMP just got a grant to do a full section on insulin safety for patients with diabetes. They are also adding a number of safety videos for consumers, a new FDA-ISMP partnership page, and a lot more is planned. The stories you will see are all original and mainly derived from the error reports that the ISMP receives through their reporting programs.

Consumers can also sign up for customized medication safety alerts.

The ISMP is a federally certified patient safety organization (PSO), providing legal protection and confidentiality for submitted patient safety data and error reports.

Systemic Error at Philadelphia VA

Today, the New York Times provides a detailed article on a disturbing case of medical error and failure of oversight at the Philadelphia VA Hospital where a practitioner failed to correctly perform 92 of 116 prostate procedures, leaving patients with radioactive seeds in tissue outside of their prostate. The mistakes were ignored and covered up until an administrative error drew the attention of the VA's national radiation safety unit.

The article correctly focuses on the lack of administrative oversight and "safety culture" that allowed these problems to continue. The article is also accompanied by a great video that highlights the personal impact on one patient.

It's a rogue's gallery of systemic problems, including:
- continued practitioner error and substandard equipment
- contractors from a well-regarded academic institution do not receive the normal level of oversight
- continuing errors are tolerated or undetected by supervisors and institutional oversight boards, and there is lack of peer review (swiss cheese at its best)
- lack of external authority to question alteration of medical records
- practitioner seen by the patient is not the practitioner performing the procedure
- patient undergoes more suffering due to subsequent misdiagnosing of the medical error by other practitioners.
- the error is finally acknowledged by the institution, but no apology or support is provided.

The unit was shut down in June 2008, and results of an investigation were recently released. Interestingly, this article is currently the #3 most forwarded article on the New York Times site.

Update: New York Times is hosting a discussion of radiation treatments. Many stories of negative experiences, but also discussion of the value of radiation treatment and treatment with few negative effects.

Patient Centered Care -- Reality or Fantasy?

There was an interesting piece in last week’s Well Blog of the New York Times. In “Letting Patients Call the Shots,” Dr. Pauline Chen talks with Dr. Don Berwick about his definition of patient-centered care. Many clinicians believe their care is “patient-centered,” but is it really? Are Dr. Berwick’s ideas too radical? Is patient-centered care a really good idea, but just not practical or realistic? Would a true commitment to patient-centered care transform the American healthcare system? What can patients do now to improve their healthcare? The questions seem endless. We’d like to hear what you think.

Impact of Medical Error Survey

You are invited to take part in a research project investigating the impact of medical error on the family members of the patient. Your participation will be a valuable contribution to patient safety research, and I strongly encourage you to participate if you qualify. If not, please pass it along to others that may be interested in the study.

The invitation that follows is offered by Sherry Worsham, a graduate student at Harvard University. MITSS has agreed to forward this research opportunity to you. We believe this study will be useful for many of us who are doing this work.
Thank you for your time.
Linda K. Kenney
President/Executive Director

You are invited to take part in a research project investigating the effect of medical error on the family members of the patient.

This invitation is offered by Sherry Worsham, a graduate student at Harvard University.

The MITSS organization has agreed to forward this research opportunity to you.Your participation in this study is completely voluntary. If you choose to participate, you will respond to questions about the medical error experience of a family member.

To be eligible to take part in the study, you must be 18 years of age or older and have a family member that experienced a medical error between the dates of January 1, 1999, and January 1, 2009.Only one member of each family in which a family member has experienced medical error should complete this study. If you are the victim of a medical error please select one family member to complete the survey.

If you completed the questions earlier or are not interested in research participation, please ignore this invitation; however, you are encouraged to forward this invitation to others that might be interested in this study.

To find more information and to tak part in this study, please click on this link: Impact of Medical Error Enter the password: CAT (all caps!)
Thank you,
Sherry Worsham
Email: sworsham@fas.harvard.edu

Emotional Impact of Medical Error Survey

Emotional Impact of Medical Error Survey

Posted using ShareThis