DC Medical Malpractice & Patient Safety Blog

Medical errors and malpractice events cost the U.S. economy $19.5 billion in 2008, according to a recently released study commissioned by the Society of Actuaries.

Of the approximately $80 billion in costs associated with medical injuries, about 25% were the result of avoidable medical errors, the study says.

Lost productivity due to related short-term disability claims cost $1.1 billion, while $1.4 billion was lost due to increased death rates among individuals who experienced medical mistakes.

The study also found that:

• There were 6.3 million measureable medical injuries in the U.S. in 2008; of the 6.3 million injuries, the SOA and Milliman estimate that 1.5 million were associated with a medical error.

• The average total cost per error was approximately $13,000.

• In an inpatient setting, seven percent of admissions are estimated to result in some type of medical injury.

• The measurable medical errors resulted in more than 2,500 avoidable deaths and more than 10 million excess days missed from work due to short-term disability.

The study also identifies the 10 medical errors that are most costly to the U.S. economy each year. Approximately 55 percent of the total error costs were the result of five common errors:

• Pressure ulcers • Postoperative infections • Mechanical complications of devices, implants, or grafts • Postlaminectomy syndrome -- back surgery • Excessive bleeding complicating a procedure

Source: Fierce Healthcare

To view the complete report, click here.

For years, patient safety experts have known that medical devices, like tubes that deliver food and drugs to hospitalized patients, need to be designed so that predictable mix-ups don't hurt patients. If a tube is safe if it goes through the nose to deliver food to the stomach, it should not be possible to hook up the same tube to a line that delivers medication to a blood vessel, since that could kill the patient.

But this basic safety philosophy -- which permeates other high-risk industries like aviation and nuclear power -- still hasn't penetrated the medical industry, as a new report in the New York Times documents in distressing detail.

Partly to blame is the U.S. Food and Drug Administration, which could set up uniform rules that would bar as unsafe any medical devices where fatal mix-ups could be easily made by hurried nurses or other caregivers.

The way the agency does its work is the problem. When the FDA has tried to act on a case-by-case basis with an application from a manufacturer for a new product, efforts by FDA safety reviewers to solve the problem have been met with cries from the new manufacturer that it is being unfairly singled out.

Efforts to have industry-wide regulations have met with years of bureaucratic delay and industry resistance.

Here's a quotable quote from former FDA official Dr. Robert Smith:

“F.D.A. could fix this tubing problem tomorrow, but because the agency is so worried about making industry happy, people continue to die.”

A newly minted M.D. doctor wandering the halls of a hospital, working long hours with little sleep as he or she begins years of residency training, can be a potential disaster waiting to happen. That's the source of the old bromide about July being the most dangerous month to get sick, since that's when residency programs start their new year.

In theory, all junior doctors receive careful supervision from senior doctors in training and from full-fledged "attending" physicians. But in practice, in busy institutions junior doctors can work long hours with little supervision, and mistakes that cause injuries to patients can result.

In 2003, residency programs accredited by the official supervisory body, the ACGME, were required to cut resident work weeks from 120 to 80 hours. But in December 2008, the Institute of Medicine, part of the National Academies of Sciences, recommended more changes to improve patient safety in residency programs.

One of them was to end the practice of 24-hour shifts.

The ACGME is now following that advice, but only in part. As of July 2011, first-year residents will be limited to 16-hour shifts, but after the first year, residents will still be able to work a 24-hour shift. Many experts believe the longer shifts are dangerous for patient safety because of sleep deprivation.

The 16-hour limit for first-years is part of a series of recommendations being submitted to the ACGME board for final approval in a few months.

Sidney Wolfe, MD., head of Public Citizen Health Research Group, is critical of the failure of the ACGME to propose a 16-hour limit across the board. He says: "The improvements in the new ACGME guidelines are largely swamped by the failure to cover the majority of medical residents with the protection of not having to work more than 16 hours continuously."

In the new proposal, first-year residents would also be barred from moonlighting at other jobs and from being "on call" in hospitals.

See the article in American Medical News for more details.

The greatest fear for any patient in the hospital, and the biggest nightmare for their families, is that something will go wrong suddenly and no one will respond until it's too late. Beeping monitors are no help if their alarms go unheeded. Patient safety experts know that one basic way to keep patients safe and prevent death or injury from malpractice is to have enough nurses on hand.

How many is enough? Nursing leaders got the state of California, after a 10-year fight with the hospital industry, to mandate minimum nurse-to-patient ratios: one nurse for every five post-surgery patients, one nurse for every two intensive care patients, one nurse for every four children in the pediatrics ward.

If you have a family member in the hospital, these numbers are worth keeping in mind. Ask the bedside nurse how many patients he or she is in charge of. And don't let hospital management confuse the issue by pointing out how many aides they have. Aides can plump pillows and give other comfort measures. But only a nurse can recognize when a patient is in peril and give lifesaving treatment.

A new study by a nursing professor at the University of Pennsylvania, Linda Aiken, asserts that mandatory minimum nurse-to-patient ratios like California's could prevent as many as 14 percent of post-surgery deaths in New Jersey hospitals and 11 percent in Pennsylvania.

Another important outcome of ensuring that nurses aren't overwhelmed by too many patients is that nurse burnout and job turnover go down, and overall quality of care improves, according to the study.

Theresa Brown, an oncology nurse in Pittsburgh, has an op-ed piece in the New York TImes asking why bills in Congress to mandate minimums nationally haven't gone anywhere.

Saving money, of course, is the issue. But that's a penny-wise answer. Saving lives can be a lot cheaper in the long run.

A tragic death in Albany, New York proves the power of the civil justice system to spur safety improvements to prevent injury to other patients.

In settling out of court a lawsuit for the death of 32-year-old Diane McCabe, who bled to death after a Cesarean section delivery, the Albany Medical Center agreed to fund for the next 20 years a Diane McCabe Memorial Quality Lecture series focusing on enhancing patient safety. The settlement also requires the hospital to buy a maternal and neonatal simulator to be used in staff training on the labor and delivery unit and to change procedures on the use of a machine that monitors a patient's vital signs during childbirth.

The attorney for Ms. McCabe's family, John Powers, said:

"It was never about the money with the family. It came down to the non-monetary aspects involved with the settlement. They wanted to do something to make certain this doesn't happen to someone else and to create a memorial to Diane for the children as they grow up that they'll know that their mother is being remembered in this way."

Read more in the Albany Times Union here.

Unfortunately the medical industry continues to push for "reforms" that would curb the right of patients and their families to seek legal redress for tragic incidents of malpractice. The industry actually argues that hospitals would work harder to improve patient safety if they were freed from the risk of lawsuits when they fail to live up to their promises. Joanne Doroshow, the author of the Pop Tort blog, has a one word response to this notion: "Pul-leze!" Read more from her column here.

American medicine is moving rapidly from small doctor-owned medical practices to large corporate-run clinics, a trend that will likely mean safer care for patients, but with a loss of close relationships with personal doctors.

Just since 2005, the percentage of doctor-owned practices has declined from over two-thirds to less than half, as doctors face a myriad of financial pressures, according to an article by Gardiner Harris in the New York Times.

Patients typically get better coordinated care in the large group practices now emerging as the model for medical practice. When doctors work together under one umbrella, it's easier to pass the patient from primary care to specialist to hospital without the communication gaps that cause so many tragedies and give rise to malpractice lawsuits. The larger practices also can better afford the electronic medical record systems that help this coordination.

Big practices also spell loosening of the intimate bond between doctor and patient, just like Costco and Walmart spelled the end of close relationships that many of us had growing up with our neighborhood merchants. But closeness and a sense of trust are much more important to the healing process than buying groceries. So the challenge for medical leaders will be to find ways to keep big medical practices from becoming too impersonal.

Whether this trend will slow rising medical costs is another question. Many of the large companies gobbling up doctors' practices are monopolies in the towns where they operate, making them more able to resist reimbursement cuts by insurance companies.

A new website has tools for learning how to speak up effectively when you've had a bad health care experience. That can be anything from being on the wrong end of someone's rudeness to being the victim of a serious malpractice event. The website is called The Assertive Patient. Click here for the link. It comes out of Massachusetts but has good resources for patients everywhere.

The website has a good diagram here that shows the steps involved in getting resolution to a bad experience, especially if it's in a hospital. You start with talking with the providers involved and if they are non-responsive, the hospital will have some sort of patient advocate or ombudsman or quality assurance officer or "risk manager" (many different terms cover the same thing). If this doesn't work, formal complaints to regulatory bodies are the next step, or talking to a lawyer.

The final chapter in my book, The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst, also gives a step-by-step approach to getting to the bottom of poor quality care. And you can get the same information at my law firm's website, by filling out the form to download our free Injury Fact Kit.

The U.S. Senate Finance Committee is investigating deaths of patients at long-term care hospitals, in follow-up to a report in the New York Times last month. That report showed that the profit-making chains who run these hospitals, which cater to chronically ill patients, sometimes skimp on staffing and training, and disasters have resulted.

More on the original report in the Times can be found in our blog entry on the subject here.

These long-term care hospitals occupy a niche between large general hospitals and nursing homes. They do not treat specific kinds of patients but are defined only by the fact that patients tend to stay longer than at a regular acute-care hospital, but less time than at a nursing home. They are typically small, with around 60 beds. Many times they lease space from a regular hospital and will occupy a floor or wing in a larger facility.

The New York Times reports that it has received new information about disturbing events at hospitals run by the Select Medical chain. One example from the Times:

According to a doctor’s deposition in a lawsuit, nurses at a Select hospital in Tulsa, Okla., injected a relatively healthy 79-year-old woman with 10 times the amount of insulin she was supposed to receive back in January 2009. They then failed to notify her doctor for at least 90 minutes after they discovered that she had fallen into a coma. The woman, Ruth Tanner, died a month later without fully regaining consciousness, according to medical records and the lawsuit.

Select Medical generally does not comment on pending lawsuits, so out of respect for the legal process and the parties involved, it will not do so in the Tanner case, the company spokeswoman, Ms. Curnane, said.

Dan Graves, an attorney for Ms. Tanner’s family, said that family members agonized after the overdose. “Now their grief and loss has been multiplied by the knowledge that other families have suffered similar tragedies because of Select’s practices.”

Deaths from preventable medical error kill as many people in the nation's capital as guns, and far more than motor vehicle crashes, according to a new report from the D.C. Department of Health.

The report, the first of its kind in the District of Columbia, analyzed the 5,168 total deaths reported to health officials in 2007. It determined that fully half of the deaths could have been prevented. Among the leading causes of preventable death:

1. Tobacco: 860 deaths
2. Poor diet and physical inactivity: 780 deaths
3. Infections (not counting HIV): 240
4. Alcohol abuse: 150
5. Firearms: 140
6. Medical errors: 140
7. Poisons (and pollution): 110 deaths

DC Motor vehicle deaths were a distant 10th place on the list of leading preventable causes of death, with 30 deaths in 2007, according to the Health Department.

Another interesting number: The Department estimates that as many people died from lack of health insurance -- which discourages access to medical care -- as motor vehicles -- 30 people in 2007.

The estimate of deaths from lack of health insurance is based on the number of uninsured people in D.C. and uses methodology from a report by the Kaiser Family Foundation. The estimate of deaths from medical error was made by applying D.C. population numbers to estimates that were made in 2000 by the Institute of Medicine, part of the National Academy of Sciences.

It sure is. Work by Peter Pronovost and other pioneers in the patient safety movement has shown over and over that medicine's culture of "doctor knows best" can be dangerous to patient safety and can cause episodes of medical malpractice. That's because nurses (still mostly female) often see errors in the making and yet feel it is not their place to criticize or correct the (usually male) physician.

Pronovost, a Johns Hopkins critical care doctor, has a new book: Safe Patients, Smart Hospitals: How One Doctor's Checklist Can Help Us Change Health Care from the Inside Out.

Changing the culture of medicine, to encourage nurses to speak up as valued members of the medical team, is critical to improving patient safety, Dr. Pronovost says.

I interviewed Peter Pronovost last year for my book, The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst. One of the things I wrote about then was how the simple culture change of having all members of the surgical team introduce themselves by name at the beginning of the operation has been found to have a big impact on improving safety. Why? Because when people know each other by name, and not just by "nurse," or "doctor," they communicate better with each other, and good communications are vital in preventing hospital errors.

Patient Safety And Sexism In Medicine

I've been thinking about sexism in medicine since the news last month about the west Texas nurse who was brought up on criminal charges for having the gumption to report a doctor she thought was endangering patients to the state licensing board. The nurse was ultimately acquitted, as reported on this blog, but of course the outrage was that she was investigated and indicted in the first place (and fired from her job at the hospital where she had watched this doctor).

It's no surprise that the nurse was female, the doctor was male, and the nurse's accusers in the sheriff's office and the local prosecutor were male too.

Of course, it's not just the gender of the people involved, but their power. Doctors admit patients to hospitals and thus are "cash cows" who are often coddled by hospital administrators for fear the doctor will take his business elsewhere.

After the Texas "not guilty" verdict, there were some interesting comments from nurses about their experiences. One posted on the San Antonio Express newspaper web site was revealing:

I am from the east coast. There, the relationship between doctors and nurses is collegial. We respect one another as licensed professionals. I was amazed that the difference here in Tx. One simple example - if a patient being admitted for chest pain, and their blood test that shows they probably had a heart attack is positive, then standard of care is that they should be admitted to a unit that can do constant heart monitoring (telemetry). Where I am from, if the doctor gave written or telephone orders for a standard unit (without telemetry), it is the DUTY of the nurse to remind him/her that the patient has a positive Troponin and needs a telemetry bed. If you did not do that, and the patient had a poor outcome, the review committee would point the finger to the nurse that took the telephone orders for admission on not taking it up the chain of command until that patient had a telemetry bed. She or he would then face a peer review and be potentially turned into their state licensing agency to determine if their license should be suspended or revoked for failure to follow appropriate patient standards of care.

I heard a nurse very politely say "doctor, would you like a telemetry bed for this patient with a high troponin level"?

His response? "Can you put a nurse on the phone that knows how to take orders"?

The issue was dropped, right then and there, and the decision to let it drop was supported by the ER and hospital nursing supervisor, because they didn't want to upset the physician. Now I have met very nice physicians here, but for the most part, this is the attitude of many physicians towards the nurses. Nurses hold a license, and have a duty to ensure quality and safety of care, in addition to taking care of the patient.This includes reporting even the SUSPICION of unsafe care. It is a shame when our ability to do so is threatened by situations like this.

This question can be answered -- perhaps unscientifically but with arresting examples nonetheless -- by just one week's worth of news. Joanne Doroshow of the Center for Justice and Democracy did a roundup of the evidence and posted her findings on the Huffington Post.

Ms. Doroshow found lots of reports of terrible injuries to patients and little accountability for the wayward practitioners except through the painful but necessary process of lawsuits in court. As she concluded:

Fixing our health care insurance system is no easy job. But this is the wrong time to consider weakening the legal liability and accountability of incompetent or reckless health care providers.

Time and again in U.S. health care, new technologies are hurried into wide use with little testing, scant training of their human operators, and lack of solid evidence that newer really is better. After the flush of optimism has faded, billions of dollars later, we learn how to judiciously use the new equipment, but only after patients have been hurt or killed by the rush to the new.

The latest example is the deployment of new radiation therapy machines on cancer patients with operators who are not properly trained or credentialed and equipment that has not been tested or calibrated. The New York Times' recent investigative series on the subject prompted one knowledgeable reader, Dr. Joseph Imperato, medical director of the Center for Advanced Radiation Medicine at Lake Forest (Ill.) Hospital. to write this:

To the Editor:

As a radiation oncologist practicing for 25 years, I believe that there is a crucial part of the story of radiation mishaps that has not been mentioned: the “nuclear arms race,” in which people want the newest technologies, without stopping to think about who is operating them.

In the past, academic medical centers were typically the first to obtain and use new technologies. The equipment would be thoroughly vetted and reported on in peer review articles before being accepted and used by the smaller community hospitals.

Now the reverse is true. Small community hospitals often far outpace academic medical centers. One example is the proliferation of proton centers run by for-profit companies. Often the staff has limited knowledge and experience with this extraordinarily complex equipment. And new technologies are often assumed by the public to be better, even though there is often little firm clinical data to support that.

As we struggle as a country to come to grips with health care costs, this is one area where there is great opportunity for savings. Clinical reviews can prevent the proliferation of needlessly expensive technology. What the public must come to grips with is that “new” is not automatically “better.”

See the Times' letters section for more.

In my book, "The Life You Save," I have several chapters that speak to this issue, particularly with new drugs. What patients need to understand is that whatever the technology, the early years of use are in essence a continuation of the testing phase. If you are comfortable with being a guinea pig, that's fine, but very often you can get better, safer care with the tried and true. And if the new technology looks enticing, go with an operator who has the most experience using it, because practice does make perfect.

More evidence of the urgent need for "checklists" to protect patient safety in complex medical treatments comes with a long article in the New York Times about terrible injuries from malpractice episodes during radiation therapy. Yet readers have to dive deep into the article to find this key point.

Scott Jerome-Parks suffered terrible radiation burns to his neck, and lingered for two years in agony before dying, because he received a seven-fold overdose in the radiation that was supposed to treat his tongue cancer, on three separate occasions. Why did it happen? The hospital, St. Vincent's in New York, blamed a confluence of tragic coincidences. But I reached a different conclusion, as I wrote in a blog post to the Times' "Well" blog:

Deep in this tragic article is the following paragraph that exposes the reforms that are needed before medical care can become safe for all patients:

"It was customary — though not mandatory — that the physicist would run a test before the first treatment to make sure that the computer had been programmed correctly. Yet that was not done until after the third overdose."

So there you have it. If the physicist had been required to run the test -- better yet, if the equipment had been set so that it wouldn't work until the final test had been run -- Scott Jerome-Parks would not have suffered the hideous injuries so eloquently described in the article.

Medicine needs to adopt standard and mandatory - not merely "customary" -- checklist routines to ensure the safety of patients. This is the thesis of Atul Gawande's new book, "The Checklist Manifesto," and I have a chapter on how patients can enforce checklist protocols before surgery in my own book, "The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst."

Many medical commenters on the New York Times "Well" blog defensively say, "We're only human," to excuse these kinds of errors. Yes! That's exactly the point of the checklist. It recognizes that we're all only human and that when we are deploying potentially deadly treatments, a final check and double-check is needed, every time, before pressing the button.

The Times also found that the manufacturer of the software that ran the linear accelerator, which delivered the radiation, did not have in place until after the injury a simple "fail-safe" mechanism to prevent the kind of error that occurred.

The entire article by the brilliant reporter, Walt Bogdanich, is worth reading. Here is the Times' own summary of the article:

The Times found that while this new technology allows doctors to more accurately attack tumors and reduce certain mistakes, its complexity has created new avenues for error — through software flaws, faulty programming, poor safety procedures or inadequate staffing and training. When those errors occur, they can be crippling.

I also recommend that readers interested in patient safety issues go through some of the NYT "Well" blog posts on this article.

A subway station might seem an unusual place to try to educate the public about protecting the rights of injured patients -- but maybe not so much when that station is the nearest to the Capitol building in Washington, D.C., and is traveled by thousands of staffers who work on Capitol Hill.

"Tell Congress to put patients first," the ads say. "There are 98,000 reasons why you should. 98000reasons.org."

The number refers to an oft-quoted report from the National Academies issued ten years ago that estimated that 98,000 patients died unnecessarily each year from medical errors.

Since then, as this blog has reported, the estimates of preventable deaths have climbed, despite a spate of efforts to make medical care safer.

The new ads are sponsored by the American Association for Justice, the lawyers' group that includes attorneys like me who represent patients in malpractice lawsuits. The ads are discussed in an article by Elizabeth Olson in the New York Times.

A physician writes in the New York Times about her own emotionally trying experience being sued for malpractice by a patient's family, and seeing the case dropped after four long years of litigation. The case happened to be against an internist for colon cancer, something where I have fresh experience. Here is the text of my comment on the Times' website:

In Dr. Savitsky’s account, it’s hard to understand how an internist would be sued for a patient’s colon cancer, and many commenters railed that this was an example of “frivolous” lawsuits or patients suing their doctors for being guilty of mere human error.

I know nothing of the facts of Dr. Savitsky’s case. But I do know how an internist can come to be sued for colon cancer. I just mailed a settlement check today to my client, a widow who lost her husband at age 59 from an entirely curable colon cancer. We successfully sued her husband’s internist for egregiously failing on multiple occasions to follow basic rules of medical practice in treating middle-aged men. I wrote more about this case a few months ago on Huffington Post.

Yes, there are occasions when our litigation system bruises people who don’t deserve it. Far more often, it is the only way that ordinary folks have to call to account those who have broken the rules and caused serious harm.

There are many other thoughtful responses to the doctor's column on the Times' site. Here is just one:

I have very mixed feelings about all of this.

It’s easy for outsiders to pass judgment on how the patient/family is supposed to feel after a bad outcome. It’s easy to apply cheap armchair psychology and decide the family is angry, or in denial, or looking for someone to blame, or that they have a lottery mentality or that they don’t know how to constructively handle their grief. The attitude seems to be that they should just shut up and be grateful for the health care they received.

Unless it’s happened to you, you really have no idea of how you’re “supposed” to feel. Take it from someone who’s been there: I was truly shocked at the level of rage and depression I experienced. I never, ever thought I would say this, but I now understand a lot better why some people sue… and I am a lot less likely to judge them harshly for it.

That said, I appreciate Dr. Savitsky’s story and I’m glad she shared it. If only we could have heard the family’s side of the story as well. Maybe then we would all have a better understanding of what the experience is like on both sides of the fence. Because right now, judging from the conversation here, most of us don’t understand.
— Perrin

An interview with patient safety leader Dr. Robert Wachter in the New York Times was both encouraging and dismaying. Encouraging because Dr. Wachter gets it right about what the medical system needs to do to make health care safer. Dismaying for some of the shrill and hysterical comments from physicians posted on the NYT blog in response.

Dr. Wachter, a hospitalist at UC-San Francisco, made a number of sensible points, including:

* Financial incentives need to be better aligned with safety. Instead, the incentives are mostly focused on getting paid by insurance companies. Quote:

"For instance, I can lose my hospital privileges if I fail to sign a dictated discharge summary or operative note. But if I don’t clean my hands for the next 10 years, nothing will happen to me."

* More honesty is needed when confronting errors. Quote:

"The only way we are going to fix this problem is to become much more open and transparent. That transparency will drive us to improve and allows us to educate each other."

* Standardizing safety routines is urgently needed. Quote:

"The chaos of everyone doing things their own way is incredibly dangerous, and it is that chaos which gets in the way of the [doctor-patient] relationship. You can make health care better, safer and less expensive while strengthening the core of the patient-doctor relationship. You can standardize certain parts of care based on clear evidence, which will free up doctors to focus on those pieces of the health care puzzle where there is no data — those issues that are uniquely human and that require judgment, expertise and empathy."

Now for the dismaying part. If you scroll through the "Well" blog comments on Dr. Pauline Chen's interview with Dr. Wachter, the ones with "MD" behind their name jump out for their ... well, judge for yourself:

A reader who identified himself as Dr. Mark Johnson: "Wachter is attention-craving sensationist, apparently employed by NYT on their anti-doctor crusade. Is he even practicing medicine? Has he ever worked outside of academia?"

Another reader who signed as Anonymous: "It’s simple. If you don’t trust the medical system, just don’t use it. Don’t come see me when you’re in a trauma. Don’t come see me when you want an elective procedure. Just don’t come see me. It saves me the energy that I waste catering to people who hate me and distrust everything I do."

Another one, who identified himself as Mark Davis, M.D., had a similar suggestion that patients should just move out of the country if they don't like it.

Back to a more encouraging take:

It was good to see many, many other readers writing in with thoughtful comments and ideas about how we can improve health care for everyone. The only ones that made me wince were those that demonized lawyers who represent injured patients. Some of them have the naive idea that if lawsuits were lessened, everyone in health care would come forward with more honest confessions about their errors, which would lead to vast improvement. The fact is that even countries with very little malpractice litigation, like England, have the same problem with the culture of secrecy in medicine.

Killing the messenger who delivers the bad news won't solve the problem.

The new breast cancer screening guidelines demonstrate yet again why savvy patients need to understand the numbers behind risk/benefit studies before making the very personal decision about whether and how often to get a cancer screening test.

The recommendations of the U.S. Preventive Services Task Force that women hold off on routine mammograms until age 50, and then get one every couple of years instead of every year, are based on sophisticated statistical modeling that aimed to get the most benefit at the least harm. The benefit is saving lives. The harm is overdiagnosing, overtreating, and needlessly frightening women who receive "false alarms" with mammograms.

The key fact that women -- and all patients -- need to understand is that your risk of a "false alarm" depends on your risk for the disease. The lower your natural risk of disease, the higher the risk of a false alarm, and vice versa. The reason the task force said that women between ages 40 and 49 don't need screening is that with the low risk of disease in that age group, the chance of needless false alarm is much higher, and the benefit of discovering the occasional cancer is much lower.

For example, one statistical model, called the Stanford model, which the task force looked at, concluded that if women between ages 40 and 69 got mammograms every year, there would be on average 2,250 false alarms -- "false positive" results -- in every 1,000 women -- an average of two per woman tested over ten years. On the other hand, there would be a total of 164 years of life gained among these 1,000 women. When the mammograms were reduced to every other year, and only given between ages 50 and 69, the years of life gained were 99 and the false alarm rate went down to 780 per 1,000. That is the tradeoff.

Those extra 65 years (164 versus 99) of life gained among the 1,000 women also come at an economic cost: if 1,000 women have to get 10 mammograms each over 10 years, that cost is around $10 million (assuming $1,000 per mammogram).

We don't like to think about "rationing" medical care, but sensible decisions on both a personal and societal level have to take into account how much we're spending for how much gain, and what else the same amount of money could be spent on.

In my book, "The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst," I have an extensive chapter on the risks and benefits of breast cancer screening at different ages. Here is an excerpt:

What about saving lives with screening tests intended to catch early cancers? Here is how that statistic of a 25 percent reduction in deaths translates in the real world. If you thought that means that of every 100 women screened, 25 of them would be saved by mammograms, you would be making a natural assumption that many others have made, but you would be very far off the mark. The actual numbers come from a series of studies in Sweden involving some 280,000 women. Of those over age forty who did not undergo mammograms, 4 in 1,000 died of breast cancer over the ten years of the study. Of those over age forty who did have mammograms, 3 in 1,000 died of breast cancer over the same ten years. The reduction from 4 to 3 per 1,000 is where the 25 percent number comes from. Put another way, for every 1,000 women who participate in mammogram screening for ten years, 1 of them will be saved from dying of breast cancer.7 The odds of saving 1 life are a little improved if screening begins only at age fifty instead of forty. Of every 270 women who start screening mammograms at age fifty and undergo one every other year for the next twenty years, 1 life will be saved—or about 4 in 1,000, which is a lot more than the 1 in 1,000 lives saved for starting mammograms at age forty.

The new statistics from the Preventive Services Task Force concluded that the benefit from mammograms in women aged 40-49 was even lower than the Swedish estimates -- more on the order of one life saved for every 1,900 women screened, instead of one in 1,000.

Here's the bottom line, as I put it in my book:

Are those kinds of odds worth it to undergo the trouble of regular screening? That is a personal decision. My only point is that to make that decision rationally and realistically, you need to look at the numbers with eyes wide open.

The recent news about the two Northwest Airlines pilots whose licenses were revoked, less than a week after they let their plane wander 150 miles off course, raises the question: Where are the firing offenses in medicine?

The pilots injured no passengers, and the event didn't even qualify as a "near miss." But because they egregiously violated safety rules by working on their flight schedules on a laptop in the cockpit, the aviation authorities did not hesitate to pull their licenses.

In the medical industry, by contrast, it is well known that a doctor will lose his or her license for only flagrant patterns of drug or alcohol abuse or other criminal behavior, with a trail of dead and injured patients usually lasting years before the practitioner is finally put out of business.

Read my entire post on this in the Huffington Post here.

One of the HuffPost comments on my blog post raised the fair point about what should be firing offenses for attorneys. Here's what I said in response:

A firing offense for an attorney should be any conduct that is unethical or negligent and hurts a client. (That's a short and probably incomplete answer to a complicated question.)

In most states, the highest court of appeals of the state has power to revoke attorney licenses. Some do a better job than others. But unlike medicine, everything happens out in the open, for the public to observe.

For patient advocates like me, the frustrating part of the medical discipline system is its secrecy and unresponsiveness. I filed a formal licensing complaint about a Maryland plastic surgeon who put a healthy patient into a permanent coma with a gross overdose of local anesthetic; two years later, I received a one-paragraph response from the state board that he had received a "private reprimand." No details available, because, after all, it's "private."

In another recent case, I complained to the Florida nursing board about a nurse-midwife whose overuse of the uterine-stimulating drug oxytocin caused the uterus to rupture and the baby to suffer terrible cerebral palsy. More than a year later, I received a one-sentence reply that the board had "failed to find probable cause."

In the law world, comparable incidents would have received at least a detailed explanation of why the licensing body was or was not taking action. That's what we should demand of any professional disciplinary system that respects the public's right to know.

The current sorry state of medical discipline is one reason I warn readers of my book, "The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst," that patients need to go way beyond looking up medical licensing discipline to make sure they are picking the right doctor for themselves.

Dale Ann Micalizzi took her 11-year-old son Justin to a hospital in upstate New York one evening because his ankle had an infection that needed to be drained. It was supposed to be a 10-minute procedure. Justin never woke up.

That happened in 2001. Today, Dale and her husband Gary head up a non-profit group called Justin's HOPE, which is dedicated to improving health care for children. She speaks often to medical staff in hospitals. One important message she gives to hospital administrators: When a mistake has happened, deal openly and honestly with the parents.

Any parent who can turn their grief into something positive is a real hero. Especially when that child has died an unnecessary, preventable death due to medical errors, the easier thing would be to retreat into numbness and bitterness. So I salute Dale Micalizzi.

I celebrate a number of heroes of the patient safety movement in my book, The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst.

You can read more about Dale's advocacy in an article in the Schenectady Gazette.

A North Carolina mother who lost her 6-year-old son to preventable medical errors writes a moving response to talk of "malpractice reform" and "defensive medicine." Laurie Sanders opens her story in the Charlotte Observer with these lines:

Medical negligence isn't a topic I gave much thought to until my 6-year-old son went to the hospital sick for the first time in his life and died of oxygen deprivation. A happy little boy, with no history of breathing problems, no allergies ... never sick. Christopher was my only son. His daddy, my husband, had died of cancer a few years earlier.

In experiencing the death of my husband and son, I have seen the best medical professionals and the worst. I have seen the most caring, and the least.

I buried my husband knowing that medical professionals did everything they could. I buried my son knowing that medical professionals failed him at the most basic level.

Ms. Sanders tells what happened to her son, including the legal investigation she launched to get at the truth, and then offers these thoughts:

One of the lessons of Christopher's unnecessary death - and my necessary lawsuit - is not that health care providers need to engage in cost-inflating "defensive medicine." Instead, it is that doctors and nurses must pay attention, communicate with their colleagues and adhere to well-recognized standards of practice.

Patrick Malone was interviewed on the People's Pharmacy radio show on how to avoid medical injuries and get the best care for you and your loved ones. You can listen to a podcast of the show by clicking here.

The hosts of this syndicated public radio show are an interesting couple. Joe Graedon is a pharmacist, and Terry Graedon is a medical anthropologist.

In their interview with Patrick Malone, Joe Graedon shares his own story about a medical tragedy that happened to his mother. The lesson: Any time you have a loved one in the hospital, you need to arrange for 24/7 presence there by a family member or close friend. It's very important to have an advocate with you at all times. Patrick Malone's book, The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst, has an entire chapter on all the ways that an advocate can help prevent injury and get you home safely from a hospital stay.

Every hospital patient needs someone with them at all times to help prevent medical errors and keep them safe. That's a mantra I have advocated for years, and another example of why it's good advice comes with a riveting story in the Washington Post by health writer Sandra Boodman.

Ms. Boodman's article tells how a Washington area woman's advocacy in the emergency room and hospital helped lead to a correct diagnosis of baffling symptoms, and likely saved her sick daughter from harm. The article interviews Patricia Dawn about her 4-year-old daughter Brooke's illness, that was eventually discovered to be Kawasaki disease, an unusual heart condition.

Brooke got the right treatment in time, but only because of her mother's persistence. Mrs. Dawn refused the recommendation of the emergency room doctors to take her daughter home at 2 a.m. when she wasn't feeling any better but they had run out of things to do. At her insistence, her daughter was hospitalized, and an infectious disease specialist eventually figured out that the red lips, red eyes, fever longer than five days, and swollen lymph node in the neck all were signs of Kawasaki, which affects about 2,000 American children a year.

It was also at the family's suggestion that the infectious disease doctor was brought in who made the correct diagnosis.

The story underlines the importance of having a good advocate present at all times with a patient in the hospital. Even a lay advocate can see when symptoms aren't improving and can insist on action.

I discuss this subject in depth in Chapter 12 of my book, "The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst."

Pennsylvania continues to lead the nation in showing how public health authorities can cast a little disinfecting sunshine onto the patient safety practices of hospitals.

In its latest report, the Pennsylvania Patient Safety Authority says that in 2008, a total of 194 surgery patients were sewed up with a foreign object still inside them. They have a term for it: RFO, for Retained Foreign Object.

To avoid leaving behind a sponge, needle or other instrument, the nurses and doctors involved in any surgery are supposed to go through a counting ritual. The problem is that the count doesn't always end correctly. In fact, the same Authority reported that last year, there were over 2,000 instances of incorrect counts, which doesn't always mean an object has actually been left behind.

One technique to follow up when there has been a discrepancy in the count is to do an x-ray of the affected area. That should show up any hidden objects.

The RFO problem is expensive for patients and hospitals. According to the Consumer Union Safe Patient Project, the average cost of a hospital stay for the corrective surgery and other problems that come from a retained object is $62,631.

A new series of investigative articles by the Hearst newspapers concludes that errors in medical facilities are still taking some 100,000 lives per year -- a decade after a national report first focused wide attention on the problem. Worse, the reforms that started after that report have been piecemeal and ineffective, according to the authors.

The series concudes:

[T]he federal government and most states have made little or no progress in improving patient safety through accountability mechanisms or other measures. According to the Hearst investigation, special interests worked to ensure that the key recommendations in the report -- most notably a mandatory national reporting system for medical errors -- were never implemented.

Among the key findings of the Hearst investigation:

• 20 states have no medical error reporting at all, five states have voluntary reporting systems and five are developing reporting systems;
• Of the 20 states that require medical error reporting, hospitals report only a tiny percentage of their mistakes, standards vary wildly and enforcement is often nonexistent;
• In terms of public disclosure, 45 states currently do not release hospital-specific information;
• Only 17 states have systematic adverse-event reporting systems that are transparent enough to be useful to consumers;
• The national patient-safety center is underfunded and has fallen far short of expectations;
• Congress approved legislation for "Patient Safety Organizations" as a voluntary system for hospitals to report and learn from errors, but the new organizations are devoid of meaningful oversight and further exclude the public;
• Hearst journalists interviewed 20 of the 21 living authors of "To Err is Human" -- 16 believe that the U.S. hasn't come close to reducing medical errors by half, the primary stated goal of the report;
• New York's reporting system has run out of money and staff -- its last public report is four years old;
• The law mandating reporting in Texas expired in 2007, and funding ran out -- a new reporting law has been passed, but no funds have been allocated;
• Washington State requires reporting, but doesn't enforce that requirement -- and the legislature failed to provide funds to analyze the results.

If there is a silver lining in this cloud, it is that safety experts now know a lot more about how patients can keep themselves safe and secure in the health care system. I report their recommendations in my book, "The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst."

A new report from Public Citizen proposes 10 cost-cutting, patient safety measures that would save an estimated 85,000 lives and $35 billion a year. The report, "Back to Basics," analyzed the results of scientific studies of treatment protocols for chronically recurring, avoidable medical errors.

In contrast to the high-tech tests and procedures that many experts blame for staggering increases in the nation’s health care costs, most of the reforms in Public Citizen’s report involve fundamentals as simple as practitioners consistently washing their hands, sufficiently tending to patients to prevent bed sores, and following simple safety checklists to prevent infections and complications stemming from operations.

Many of the proposals on Public Citizen's list are the same that I discuss in my book, "The Life You Save." The only difference is that I believe patients and families can do their own health care reform at home to implement many of these safety measures. I discuss examples of things patient advocates can do at the bedside to help prevent pressure ulcers (bed sores), injuries from falls, blood clots, infections and medication errors. See Chapter 12: "Your Personal Advocate, in the Hospital and Out," and Chapter 13: "The Scandal of Infections in Hospitals and Other Health-Care Facilities, and What You Can Do."

Here is more from Public Citizen's news release announcing their new report.

Aside from the tragedy of needless deaths and injuries, the financial toll of failing to follow accepted safety procedures is astounding. Severe pressure ulcers cost an average of $70,000 apiece to treat. A catheter infection costs $45,000. Each instance of ventilator-associated pneumonia costs $5,800. Collectively, avoidable surgical errors cost an estimated $20 billion a year, bed sores $11 billion and preventable adverse drug reactions $3.5 billion.

"There are many incentives to order expensive tests and procedures and too few rewards for providing basic, sensible care," said David Arkush, director of Public Citizen’s Congress Watch division. "As the largest investor in the nation’s health care system, the federal government should ensure that fulfilling basic patient safety standards is a condition of receiving federal reimbursements. And the government should pay providers for doing the right thing. It will save money in the long run."

Public Citizen proposes that health care providers:

• Use a checklist to reduce avoidable deaths and injuries resulting from surgical procedures (saves $20 billion a year);

• Use best practices to prevent ventilator-associated pneumonia (saves 32,000 lives and $900 million a year);

• Use best practices to prevent pressure ulcers (saves 14,071 lives and $5.5 billion a year);

• Implement safeguards and quality control measures to reduce medication errors (saves 4,620 lives and $2.3 billion a year);

• Use best practices to prevent patient falls in health care facilities (saves $1.5 billion a year);

• Use a checklist to prevent catheter infections (saves 15,680 lives and $1.3 billion a year);

• Modestly improve nurse staffing ratios (saves 5,000 lives and $242 million a year);

• Permit standing orders to increase flu and pneumococcal vaccinations in the elderly (saves 9,250 lives and $545 million a year);

• Use beta-blockers after heart attacks (saves 3,600 lives and $900,000 a year); and

• Increase use of advanced care planning (saves $3.2 billion a year).

Swine flu testing is the latest example of an important issue for informed patients. Patients need to understand that some medical tests are valuable if there is a "positive" finding, but not much good at all if they are "negative." The problem is that the test is "insensitive," which means a negative result can miss the disease that's really there -- a "broken alarm."

For swine flu, in every 100 patients who actually have flu, the various brands of "rapid flu" tests will have a "positive" result (meaning the patient has the flu bug) for as few as ten of the 100 patients, or as many as 69 of the 100 patients. Even with the higher accuracy, that means that a lot of patients are being missed by these "rapid flu" tests. These statistics come from a New York Times article quoting newly published studies and experts in the field including the Centers for Disease Control and Prevention.

A CDC official told the Times:

“We’re saying you need to understand the limitations of these tests,” Dr. Timothy M. Uyeki, an author of the C.D.C. guidance, said in an interview. “The clinician should not base a decision to treat or not treat on the basis of a negative result.”

Another classic example of an "insensitive" test is the "hemoccult" test for hidden blood in the stool. If it's positive, you need further workup. If it's negative, it doesn't give you a clean bill of health for colon cancer. That's why the standard screening test for colon cancer is a colonoscopy, which looks at the entire length of the colon with a video camera.

My book "The Life You Save" has a chapter about understanding medical testing and why you cannot necessarily rely on a negative test result.

The point is: A negative result doesn't mean you have a clean bill of health. Sometimes you have to pay attention to other signs and symptoms.

One hundred thousand preventable deaths from medical errors in hospitals each year: That is the usual statistic cited by patient safety advocates. It comes from a 10-year-old report issued by the Institute of Medicine of the National Academy of Sciences. The fact is, though, that the death and injury rate could be substantially higher. No one is sure, because no one is counting "adverse events" in a rigorous, systematic way, and evidence keeps piling up that hospitals under-report these events to health authorities and worse, cover them up.

An investigation by the New York Daily News of the city's municipal hospital system -- with eleven hospitals and 1.1 million patients treated last year, the nation's busiest city-run system -- found dozens of examples of failures to report egregious errors, and subsequent cover-ups including alteration of medical records to make it look like nothing had gone wrong.

The Daily News reported:

The coverups hid a trail of human suffering among patients who were maimed and relatives who were never told the truth about how their loved ones died or were injured unnecessarily.

The newspaper found a pattern of failures by state health authorities to act on evidence of fraudulent behavior in covering up the injuries. Moreover, it found that the state reporting agency itself was dysfuctional. According to the article:

The state is supposed to track and analyze all medical incidents and implement improvements. The problem is this oversight system — the New York Patient Occurrence Reporting and Tracking System (NYPORTS) — is a disaster.

Since 1999, all New York hospitals have been required to self-report a long list of medical incidents to NYPORTS, which in turn analyzes the incidents and implements patient safety reform.

Sunday NYPORTS barely functions. The Statewide Council that oversees it hasn't met in more than two years. Though NYPORTS is supposed to release "annual" reports, the last one filed is dated 2004.

To avoid needless injury, patients have to be vigilant about their own health care. That is why I wrote my book, "The Life You Save," which lays out a system of nine simple steps for patients to follow to get the best medical care and avoid the too-frequent disasters that happen in our fragmented care system.

Imagine if every 50-year-old woman thinking about whether to have a mammogram received the following "balance sheet" showing the "credits" and "debits" as understood by the latest research:

For every 1,000 women who have a yearly mammogram over the next ten years: Credits

1 woman will avoid dying from breast cancer

Debits
2-10 women will be overdiagnosed and treated needlessly

10-15 women will be told they have breast cancer earlier than they would otherwise have been told, but this will not affect their prognosis

100-500 women will have at least one "false alarm" (about half of these women will undergo a biopsy)

These numbers appear in an editorial in the British Medical Journal in July 2009, written by Dartmouth researcher H. Gilbert Welch, M.D., in response to news that the British National Health Service had scrapped a proposed pamphlet that would have described the benefits of mammograms, but failed to talk about their downside.

The key comparison in the above balance sheet is the ratio of one woman's life saved for every two to ten lives harmed by overdiagnosis. The one-to-two ratio comes from a study three years ago by Zackrisson and colleagues. The one-to-ten ratio is from a more recent study by Gotzsche. The tipping point for women in deciding whether to undergo annual mammogram screening is probably somewhere on this sliding scale. The test might not feel worthwhile if ten women are hurt for every one helped, but might seem worth it if only two were hurt for every one helped.

As the author writes:

Mammography is one of medicine’s "close calls"—a delicate balance between benefits and harms—where different people in the same situation might reasonably make different choices. Mammography undoubtedly helps some women but hurts others. No right answer exists, instead it is a personal choice.
To inform that choice, women need a simple tabular display of benefit and harms—a balance sheet of credits and debits.

Unfortunately, medicine hasn't yet pinned down the precise numbers on the balance sheet. For now, women need to be informed that there are varying estimates, and they need to make their own decisions.

Readers should note that this discussion applies only to cancer screening in low-risk women who have no noticeable lumps; women who can feel a lump in their breast are in a different risk category and need to see a doctor promptly.

A column in the New York Times by Pauline Chen, M.D., relates how a colleague of hers named "Ed" crashed and burned on his way to becoming a general surgeon, seemingly because of his difficulty in learning from his own mistakes.

The blog comments by both doctors and patients are revealing. Many make the point that physicians can deal with the stresses of medical practice, and become better at their craft, by being less obsessed with perfection and more open to working with others in a supportive, teamwork environment. I particularly enjoyed a comment (No. 121) from "Susan," that linked the issue to the recent story by Jane Gross in the Times about the Sisters of St. Joseph near Rochester, New York, who have figured out that putting the patient's wishes at the heart of the enterprise makes for more humane and better health care.

Here is the comment I posted on the Times' site:

Susan’s comment is right on target. A team ethic, and the recognition that “we’re all in this together” — patients included, goes a long way toward making the inevitable small mistakes a teaching moment rather than one step toward a disaster for the patient. And when disaster does happen, honesty is always the best policy. I represent patients in lawsuits against hospitals and doctors, and can say emphatically that the medical industry could greatly reduce its exposure to legal actions if hospitals and doctors would just respond with maturity and complete candor when mistakes happen.

One more change in philosophy could help reduce the toll of medical error. If patients were more involved at every step of the process, we could help nip a lot of disasters in the bud and get better care for ourselves and loved ones. There is much that we can do, starting with reading our own medical records. I just wrote a book about this called “The Life You Save: Nine Steps to Finding the Best Medical Care — and Avoiding the Worst.” Chapter One can be read at http://www.lifeyousave.com.

Malpractice payouts to injured patients and families declined for the third year in a row and amount to somewhere between 0.18% and 0.6% of U.S. medical costs, according to a new study from Public Citizen.

It would be great if improved patient safety was responsible for the decline, but that is highly unlikely, according to the consumer group's analysis, which said that the reduced payouts appear to be because fewer injured patients are being compensated.

The study also undercuts the idea that the system is glutted with large numbers of "frivolous" lawsuits. According to a press release from Public Citizen:

More than 80 percent of the money paid out for medical malpractice in 2008 was for cases involving "significant permanent injuries"; "major permanent injuries"; injuries resulting in quadriplegia, brain damage or the need for permanent care; or death, according to NPDB [National Practitioner Data Bank] reporting.

Despite the hysteria surrounding debates over medical malpractice litigation, experts have repeatedly concluded that several times as many patients suffer avoidable injuries as those who sue. The best known such finding was included in the Institute of Medicine’s (IOM) seminal 1999 study, "To Err Is Human," which concluded that between 44,000 and 98,000 Americans die every year because of avoidable medical errors. Fewer than 15,000 people (including those with non-fatal outcomes) received compensation for medical malpractice that year, and in 2008, the number receiving compensation fell to just over 11,000.

As an advocate for patient safety and author of a new book on how we can all improve the quality and safety of the health care we receive, I agree that the only humane way to reform medical malpractice is to take seriously patient safety and implement systematic improvements to cut the numbers of injuries.

Elderly patients are different. They are more sensitive to some drugs, less to others, have unusual presentations of common conditions, and otherwise are not that easy to diagnose and treat when the doctor is used to dealing with younger patients.

Bemoaning the lack of required geriatric training in medical schools, geriatrician Dr. Rosanne Leipzig gave this example in a recent op-ed piece she wrote in the New York Times:

Often even experienced doctors are unaware that 80-year-olds are not the same as 50-year-olds. Pneumonia in a 50-year-old causes fever, cough and difficulty breathing; an 80-year-old with the same illness may have none of these symptoms, but just seem “not herself” — confused and unsteady, unable to get out of bed.

She may end up in a hospital, where a doctor prescribes a dose of antibiotic that would be right for a woman in her 50s, but is twice as much as an 80-year-old patient should get, and so she develops kidney failure, and grows weaker and more confused. In her confusion, she pulls the tube from her arm and the catheter from her bladder.

Instead of re-evaluating whether the tubes are needed, her doctor then asks the nurses to tie her arms to the bed so she won’t hurt herself. This only increases her agitation and keeps her bed-bound, causing her to lose muscle and bone mass. Eventually, she recovers from the pneumonia and her mind is clearer, so she’s considered ready for discharge — but she is no longer the woman she was before her illness. She’s more frail, and needs help with walking, bathing and daily chores.

This shouldn’t happen.

Dr. Leipzig co-authored an article for medical educators listing 26 areas of competency in treating elderly patients that medical students should have to demonstrate before getting out of school; the list is nicknamed the "Don't Kill Granny" list.

For the rest of us, the takeaway lesson is that when we're advocating for an elderly relative with a new doctor, we need to find out if the doctor has deep experience in treating elderly folks, and if not, ask for a second opinion from a doctor who does. This can make a huge difference in quality of medical care -- and quality of health for our relatives' twilight years.

More tips on being a patient advocate can be found in Patrick Malone's new book, "The Life You Save."

Evidence continues to pile up for why patients need to read their own medical records. A new study finds it is distressingly common for primary care practices, especially big ones, to fail to inform patients about abnormal test results.

The study was published in the Archives of Internal Medicine and was reported by Nicholas Bakalar in the New York Times. The study was also featured in Tara Parker-Pope's "Well" blog at the Times, which features a number of horror story comments by readers.

Overall, the study found seven times out of 100, abnormal test results were not conveyed to patients. In two large primary care practices, one in four abnormal test results were never mentioned to the patient.

Bottom line: Patients who don't hear back the results of their testing can never assume that no news is good news. People need to ask for a copy of their test results from either the doctor's office or the lab where the test was done.

Getting and reading your own medical records is Step One in the nine-step system I recommend for getting the best medical care, in my book, "The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst."

Several thought-provoking letters to the editor in the New York Times address this issue in the context of the current health care reform battle. One of the letters is from Patrick Malone and says:

To the Editor:

The reason malpractice is expensive and burdensome is not any unfairness in the system, but because too many patients are being hurt every day in a system that has failed to use basic safety checklists that have made injuries rare in other high-risk industries.

When the hospital industry’s own two-year pilot project to improve safety is called the Five Million Lives Campaign, we can see that the true urgency of reform lies in safety and quality.

“When the right care is delivered to the right patient at the right time, every time” is how Elizabeth A. McGlynn, a RAND Corporation researcher, defined quality care. And when we achieve that, malpractice lawsuits will no longer be the “burden” that some doctors perceive. Patrick Malone

Chevy Chase, Md., June 17, 2009

The writer is a lawyer and the author of “The Life You Save: Nine Steps to Finding the Best Medical Care — and Avoiding the Worst.”

--

Another Times letter writer makes the point that we should have public report cards on hospitals and doctors that would give patients basic safety and quality information so we could make intelligent choices about who cares for us. That's an idea worth doing.

Patrick Malone had a recent blog post on the Huffington Post that discusses the "medical hit-and-run" -- preventable injuries that happen to patients where the doctors and nurses pretend nothing happened. The comments below his blog post are interesting.

All responsible attorneys would like nothing better than to reduce the number of lawsuits that have to be filed seeking accountability on behalf of injured patients. But the way to do that is with comprehensive safety programs that reduce the number of injuries.

A new report from Consumers Union says too many patients are still dying every year from needless errors. The report makes a number of proposals for how reforms could be instituted to improve patient safety. A starting point will be to change the health reform debate in Washington from one of just access and money to one focusing on quality and safety.

Nearly 10 years ago, the Institute of Medicine estimated that nearly 100,000 people died each year from preventable medical error. Has there been any substantial improvement in the last decade? The Consumers Union report says the frustrating answer is "We don't know" -- because systems to methodically measure and report harm are still not widely in place.

What should consumers push for?

* A national system with mandatory reporting of all infections acquired in health care facilities and other harms from preventable errors.

* More widespread adoption by hospitals of computerized systems for ordering and dispensing drugs to cut medication errors.

Those are the key steps called for by the Consumers Union report. Here's one more that I advocate in my new book, The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst -- a "single payer" system. How would having a government-paid health care system help with safety? For starters, it would allow much easier monitoring of quality and errors. Instead of cobbling together data from dozens of insurance companies about how patients did at a particular hospital, all the data would be centralized and could be easily analyzed and compared. That way, problems with care could be more easily identified before tragedies occur.

Families of active duty military service members sometimes learn too late a shocking fact about the military medical care system: lack of accountability when someone has been injured or killed by malpractice. The latest victim is Cindy Wilson, an Air Force technical sergeant who bled to death after a cesarean section delivery due to an artery that was cut during the operation and not found until she had lost an entire body's volume of blood.

As described in an article by Bill Sizemore in The Virginian-Pilot, after the death of their 37-year-old daughter at Langley Air Force Base, Tommy and Connie Wilson learned about the "Feres doctrine." That is the name of the U.S. Supreme Court decision from 1950 in which the Court ruled that the military was immune from lawsuits concerning injuries to active duty service members caused by negligence of other service personnel, even if that malpractice was egregious.

George Washington University law professor Jonathan Turley was quoted in the article as calling the Feres doctrine "one of the most grotesque rules created in the history of this republic" - because it encourages lack of safety practices in military hospitals.

If military doctors injure someone who is not active duty military (such as a military family member or a veteran retired from service), the government is not immune from accountability. So if Ms. Wilson's baby boy had been hurt during the delivery in which she was killed, the family could have sued for his injuries. But because she was active duty, the government was immune from suit under the Feres doctrine. Because that difference doesn't make sense, a bill is now before Congress to lift the government's immunity from malpractice cases no matter who the victim is.

You can read more about legal issues surrounding military malpractice at a special section of Patrick Malone's law firm web site.

Getting a loved one home from the hospital is always a relief for both patient and family, but the weeks immediately after hospital discharge are fraught with peril, as many families don't discover until the patient has to be readmitted for a new problem. This is especially common with Medicare patients: an alarming one in five Medicare patients are back in the hospital within thirty days, and one in three are readmitted within ninety days. Fully half of the non-surgical patients who have to be readmitted in the first month after going home had no followup visit with any doctor during that same month. That means the patients were basically set adrift to fend for themselves. These numbers come from an analysis published in the New England Journal of Medicine, as reported in an editorial in the New York Times.

Leaders in the health care field freely admit that hospital readmissions come about from poor discharge planning and inadequate communication with family members about what they need to do to keep the patient healthy. The president of the American Hospital Association said in a letter to The Times about the editorial: "Most unplanned readmissions can be traced back to our fragmented delivery system, and to the lack of social support programs for many elderly and sick patients."

What is the answer?

Family members who are assigned by hospitals to take care of a loved one at home need to be very clear on what they are supposed to do. Do not let a family member be dumped on your lap without a clear, written list of everything they need, including medications, therapies, and appointments for return visits. Family members need a lifeline they can call on when things don't seem to be going right.

The leaders of our health care system are talking about extending Medicare benefits so that nurse managers can coordinate the transition from hospital to home, or teams of caregivers can conduct house calls on recently discharged patients. These are promising ideas, but what is needed right now is for anyone who has a family member coming home from the hospital to speak up and insist on clear instructions and advice. Being forceful and clear can help the caregivers help you to make sure there is a well thought out plan and that you can realistically carry it out.

Patrick Malone's new book, The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst, has a chapter on how family members can become effective patient advocates when they have someone in the hospital. The chapter includes a list of key checkoff points that you need to understand when a loved one is discharged to your care. You need to have at a minimum:

* A written set of discharge instructions.

* A specific appointment with the doctor in charge for a followup visit.

* A list of bad things to watch out for, and the contact person to relay this information to.

* Written lists of all medications that need to be taken, when and how; plus all therapies that need to be done with similar detailed instructions.

One of the true pioneers of modern medicine is Dr. Thomas Sarzl, who performed the first liver transplant and who developed many of the procedures that have made transplantation a safe lifesaving treatment for thousands of people.

Dr. Sarzl is still active at age 83. He was interviewed recently by another transplant surgeon, Dr. Pauline Chen, for her column in the New York Times.

From his many years of experience, Dr. Starzl gave three nuggets of advice to patients, which I am reprinting because I think he is right on target:

"As for the patients," he told Dr. Chen, "I would give this advice — I followed it myself. That is to get a practitioner of general medicine to take care of you, somebody who is not a narrow specialist. And have that person take care of yourself and the people you care for most, your family. The second is to be constantly learning so you can be informed and have some judgment about advice you are given. And then the third item would be to get a second opinion if some really significant thing happens that requires drastic therapy. Those decisions are so important that I think you should get a second opinion if you come to a point where you need the treatment required for cancer or transplantation or catastrophic indications."

My new book, "The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst," makes some of these same points. For example, Step Three of my "nine steps" says: "Team up with the best primary care doctor you can find." And Chapter 9 is titled: "The Second Opinion: Always Your First Choice."

Victims of medical malpractice won a big victory in a Maryland court this week when a judge refused to reduce a jury's verdict in a wrongful death case to the artificial "cap" on damages set by the legislature.

The case is Semsker vs. Lockshin, in which Patrick Malone and Associates represents the family of a Montgomery County, Maryland attorney who died at age 47 from a highly curable skin cancer. Treatment of the cancer was delayed for years because of the combined negligence of Mr. Semsker's doctors. Click here for more case details and a link to Mr. Malone's closing argument in the trial, which was held in November 2008.

Four years ago, the Maryland General Assembly passed a statute under pressure from the medical lobby which cut in half the amount of money that a malpractice victim could recover in a wrongful death lawsuit from a doctor or hospital in "non-economic" damages. Those are general damages for the victim's suffering and the family's loss of companionship with their deceased loved one.

Now the judge who presided at the Semsker vs. Lockshin trial has ruled that the "plain meaning" of the statute as worded eliminated the cap from all cases except those in which the parties had arbitrated the case before suit was filed. Read more about the judge's decision in the Maryland Daily Record article.

This case is very significant for Maryland victims of medical malpractice, who are freed by this ruling from the onerous and unfair damage “cap” that acts as a regressive tax on the most injured patients.

Patrick Malone commented: “On the same day as the judge’s ruling, a report was released that shows Maryland ranks 45th among the 50 states in its rate of disciplining doctors who harm patients. Rather than trying to win special protection from the legislature to shield doctors and hospitals from accountability for the injuries they cause, the medical leaders of Maryland should clean up the disciplinary process so that the truly dangerous doctors are weeded out.”

The report Malone referred to was the annual ranking published by Public Citizen of physician license disciplinary boards. It can be accessed here.

The U.S. Supreme Court has rejected a strong push by the pharmaceutical industry to win immunity from lawsuits filed by injured plaintiffs. In a 6-3 decision in the case of Wyeth v. Levine, the Supreme Court ruled that the Food and Drug Administration's approval of a drug's label does not mean that the manufacturer has no obligation to improve the warnings on the label if new information comes to the attention of the manufacturer.

This is a big victory for patient safety. The case will help doctors too, by keeping the pressure on the drug manufacturers to keep their product labels up-to-date so that doctors can be educated about the safest way to use drugs. Medical leaders, such as a group of editors of the New England Journal of Medicine, had filed "friends of the court" briefs urging the Supreme Court to take the side of the injured patient.

The heroic patient who pushed this case was Diana Levine, a Vermont musician who lost her arm and her career after being injected too rapidly with an anti-nausea drug called Phenergan. The drug is well known to cause terrible injuries if it gets into an artery. She contended, and the jury and the Vermont Supreme Court agreed, that the drug's manufacturer, Wyeth, knew about this risk and should have warned doctors on the label to avoid the "i.v. push" technique that carried a high risk of inadvertent injection into an artery.

It's always intimidating to undergo an MRI scan or CT scan. The machines are loud and enormous and seem to swallow your body. For all the trouble and expense, patients deserve the very latest scanning equipment and should have their images read by only the most highly qualified doctors. Alas, there is a quiet scandal in the $100 billion/year medical imaging industry. Patients cannot count on the best unless they insist on it.

As quoted by Gina Kolata in the New York Times, radiology leaders say, in the words of one: "The system is just totally, totally broken." That from Dr. Vijay Rao, chair of radiology at Thomas Jefferson University Hospital in Philadelphia. One big problem is that insurers pay standard rates for scans, even if a scan on a 10-year-old machine produces a blurry image and results in patients undergoing unnecessary surgery or missing a diagnosis. There is also no financial incentive for scanning facilities to have the images interpreted by sub-specialists with more expertise in the body part being studied. But there is a big financial incentive for doctors to own their own scanning equipment, and that results in many unnecessary referrals for scans when the doctor's judgment about the patient's needs is clouded by financial conflicts of interest.

Wise patients should ask pointed questions before submitting to any imaging scan. Here is a list, adapted from Patrick Malone's new book, The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst, available at Amazon.

1. Is the scanning machine the latest generational available? If not, is there another facility nearby that has the latest generation? (In MRI scans for example, the stronger magnets on newer machines make for crisper images.)

2. Does the doctor who wants me to have this scan own the scanning equipment or the scanning facility? (If so, get an opinion from another doctor with no financial interest about whether you need the scan at this facility.)

3. Who will interpret the images? Is that doctor a sub-specialist in what's being studied? (Examples of radiology sub-specialties include musculo-skeletal, neuroradiology (brain and spine), abdominal and chest.) If not, can we get a second reading from a sub-specialist?

4. Is the scanning facility accredited by the American College of Radiology? (This ensures that basic standards are met, such as the technologist who runs the scanning machine being certified and the machine being regularly inspected for proper functioning.)

Involved patients will also want to sit down with the doctor and look at the images together. You will notice how much more detail comes out when the scan has been done on an up-to-date machine by well-trained personnel. In the New York Times article, you can see in a knee scan how the ligament is blurry on the left-side image but comes out clearly in the image on the right -- a slanting striated structure that connects the middle of the top of the tibia to the back of the femur.

When a doctor knows that his patient would receive better care elsewhere, should he inform the patient and send him to another provider? While this question is yet to be settled among bioethicists and physicians themselves, authors of an article published recently in the journal, Public Library of Science Medicine, think doctors have an ethical obligation to tell patients that better care is available to them, according to the New York Times’ Denise Grady.

Research has shown that facilities that perform high volumes of a certain procedure do it better than those that perform the procedure less frequently. The difference is substantial, especially in surgeries of pancreatic and esophageal cancer, although “the experience of the surgeon and the whole medical team [is] important in any major cancer surgery.”

Only a few courts around the country have decided whether doctors have a legal duty to inform patients that another doctor might have more skill and experience performing a planned surgery. One of them is Maryland's highest court, the Court of Appeals, thanks to a client of Patrick Malone named Billy Boone who suffered brain damage after an ear surgeon punched a hole into Mr. Boone's brain.

Mr. Boone's case shows that surgeons' skills make a difference in much more than cancer surgeries. The Maryland Court of Appeals decided that Boone had a legal right to know that his surgeon did not have extensive experience doing the ear surgery that Mr. Boone underwent.

Mr. Boone had an outpatient surgery in January 2000, to remove a benign growth from the mastoid cavity behind his left ear. Dr. Seth Goldberg, an ear nose throat surgeon, performed this surgery, called a mastoidectomy. Seventeen years before, Mr. Boone underwent the same procedure, in which another surgeon drilled out the same mastoid to remove a cheesy growth of skin debris called a cholesteatoma. Unknown to Boone, the surgeon had become lost at one point during the procedure and drilled a hole in the skull just above the mastoid, near the bottom of the brain's temporal lobe. But nothing happened to his brain, which was protected by the tough fibrous shell below the skull called the dura. Years later, when Dr. Goldberg prepared for the new surgery, he took some CT scan pictures of the bone anatomy and saw the pencil-sized hole in the side of the skull.

Dr. Goldberg's surgery seemed uneventful, but after Boone went home, he developed a short-term memory problem that ruined his ability to do carpentry; worse, he developed a problem controlling his temper that unleashed itself at stressful moments on whoever happened to be nearby. Later, his neurologist explained to the jury that Boone's outbursts could be traced to injury in the limbic system that modulates emotional response.

A CT scan showed that a hole had been poked from the pre-existing skull defect into Boone's brain. A small pocket of air could be seen in the temporal lobe, surrounded by a pool of blood. But it wasn't just air in the brain – it was something slightly denser than air, likely surgical gelfoam which could have made its way there only if Dr. Goldberg had pushed it in to try to stop bleeding after he punched the first hole.

The key moment for Mr. Boone came not in the surgery but a month before, when he sat down with Dr. Goldberg to go over the planned operation. Goldberg never volunteered the key information: that with the hole in the skull from the prior surgery, his surgery would be that much more difficult, could even result in an injury to the brain, and Mr. Boone might benefit from consulting with someone who regularly did "revision mastoidectomies," the technical term for this second go-round. A general ENT doctor who advertised his specialty in facial cosmetic work like nose jobs – he named his professional corporation the "Aesthetic Facial Surgery Center of Rockville" – Goldberg only had done occasional revision mastoid surgeries. His operation on Boone proved he wasn't up to the job. On the witness stand, Goldberg admitted he hadn't discussed with Boone the hole in the skull, the chance of brain damage, or the availability of sub-specialists called neurotologists. For Billy Boone, the jury's vote in his favor, and the Court of Appeals' affirmance of the award, gave him some vindication. For other patients, his win makes it easier to demand the information you need to make a sensible selection among surgeons. Of course, if you asked Billy Boone, he would trade in legal vindication for a healthy brain any day. It's too late for him, but not for the rest of us.

(Click here for more information on the Boone case, and follow this link to Mr. Patrick Malone's closing argument.)

Colonoscopy is widely known as a powerful screening/early detection test for colorectal cancer, capable of preventing, or so it was thought, up to 90% of cancers. However, recent studies show that colonoscopy misses many cancers, according to the New York Times in an article by Gina Kolata.

A newly published Canadian study documents the low success rate of colonoscopy in picking up cancer in the right side of the colon, an area where 40 percent of cancers occur. In the left side of the colon, the area directly above the rectum, where cancers should be easier to detect, colonoscopy missed a third of occurrences.

Does that mean patients should dismiss colonoscopy as an ineffective test? Quite the contrary. Although colonoscopy is now found to prevent only 60% of colon cancer deaths, it’s still “a good test,” said Dr. Ransohoff, gastroenterologist at the University of North Carolina. In the Times article, Kolata points out that colonoscopy works relatively well, in contrast with other screening tests: Mammograms prevent 25 percent of breast cancer deaths and the Prostate-Specific Antigen (PSA) test has not been proven to prevent prostate cancer deaths.

In addition, patients can help maximize colonoscopy’s effectiveness by doing their homework. Dr. Douglas Rex, Indiana University’s director of endoscopy and professor of medicine, said that polyps in the colons may be obscured if patients did not thoroughly cleanse the bowels. Taking half of the laxative the night before the test and the other half in the morning – a procedure not always done – can help clear out patients’ systems and improve the visibility of the inner wall of the colon.

Researchers also urge patients to seek out the best colonoscopists who are skilled in performing the test consistently. Patients should ask how many colonoscopies the doctor does each year (a good volume would be three to four colonoscopies a day), what percent of those turn up polyps (it should be around 25% in men and 15% in women; much lower suggests that the doctor is missing some), and how long the scope is in the colon (colonoscopists should take at least eight minutes to withdraw the endoscope; too short a time suggests a hurried look).

A torn meniscus that shows up on the MRI scan may not be the reason why your knee is hurting. For Cheryl Westein, who demanded an MRI and saw a torn cartilage on the scan, the culprit behind her painful knee was actually arthritis. Gina Kolata in a New York Times article reports recent scientific findings that further support what many physicians already believe: radiological imaging is a presurgical tool and “does not help with a diagnosis.”

Dr. Felson and Dr. Modic, in their separate studies, found that abnormalities in scans are common and are not conclusive evidence of a diagnosis. For example, 60 percent of healthy people who do not complain of back pain will turn out to have degenerative changes in their spines. Many abnormalities go away on their own in a few months, requiring no medical intervention.

Relying on scans for diagnoses can lead referring physicians to recommend “unnecessary or sometimes even harmful treatments, including surgery.” If the root cause of the knee pain is arthritis and not the torn meniscus, the pain will return even after a surgery repairing the meniscus, as the arthritic bones continue to wear down the cartilage.

It is important for patients to know that getting radiological imaging is often not the best way to find out what is causing their discomfort. More importantly, since scans reveal abnormalities that may not be “catastrophic findings”, doctors could be misled to recommend harmful regimens that result in extra expenses.

Despite reforms in medical training, many resident doctors are still sleep-deprived and therefore more likely to make mistakes than well-rested doctors in training, according to an Institute of Medicine study, as reported by Tara Parker-Pope of the New York Times.

In 2003, the Accreditation Council for Graduate Medical Education capped resident doctors’ working hours at 80 per week. Before that, young medical school graduates could average 110 hours a week. But even now, with the hours capped at 80 hours a week, the Institute of Medicine report reveals that there are common violations of the 80-hour cap, although residents rarely complain. Eighty hours itself is a demanding routine even without the excess hours.

Consequences of sleep deprivation are many – including irritability, impaired judgment, and inability to concentrate – and each of these can debilitate the doctors in performing and thinking through their tasks. For better patient care and the health of the resident doctors, the Institute of Medicine recommends allowing an uninterrupted nap time for up to five hours.

It's not clear from this latest study how reform will be instituted and who will pay for it. Leaders in the field acknowledge that it will be expensive to put in place the same kind of mandatory rest periods that workers in other industries, like truck drivers, have.

A recent medical malpractice lawsuit prosecuted by Patrick Malone & Associates for the victim of a delayed diagnosis of skin cancer highlights the need for annual skin checks by a qualified doctor. Anyone who is fair-skinned, sunburns easily, or has a lot of moles on their skin should see a dermatologist or a good primary care doctor for annual skin checks. These can be part of a routine physical exam. The doctor should measure and do sketches of the moles' location and appearance on your skin, or should take good photographs. A change in a mole is one of the key indicators of potential for malignant melanoma, a skin cancer which is deadly once it gets into the bloodstream but is 100% curable when still confined to the skin. Patients and their families often don't notice subtle changes in a mole -- getting bigger, changing color, etc. -- that health care providers can pick up.

In the legal case of Semsker v. Lockshin, a benign mole on the patient's lower back turned into a deadly melanoma over an eight-year period, during which time the mole's presence and change in size was documented by the dermatologist. The lawsuit alleged the dermatologist should have removed the mole two years before it finally was removed, when it had already invaded the patient's lymph nodes. Mr. Semsker died 14 months after the diagnosis.

In their defense of the malpractice lawsuit, the dermatology practice of Norman Lockshin, M.D., P.A., contended that they would have told the patient to get skin checks even more often than he was (every few years from either his primary doctor or his dermatologist), although this recommendation was not documented in their records.

Regardless, every patient needs to know about the dangers of melanoma and the need for regular skin exams. Exams should focus on the ABCDE's of skin cancer: A for Asymmetry of the mole; B for irregular Borders; C for variegated Color or unusual color in the mole; D for diameter greater than 6 millimeters, and E for Evolution or changes in the mole's size, shape or color.

Patients who go in for MRIs are often told nothing is wrong, when in fact the scan is of poor quality and so misses the problem, as Gina Kolata's story demonstrates.

Doctors all agree that it is a good idea to get MRIs and other scans done at centers accredited by the American College of Radiology. But, they caution, there is a wide range of quality among those centers. Quality depends on the quality of the imaging coils put around the body part being scanned, the skill of the technicians and the expertise of the doctor reading the image:

At Massachusetts General Hospital, for example, Dr. Gazelle said, “musculoskeletal M.R.I.’s are read by someone who does musculoskeletal imaging every day” — and not “by someone who reads chest M.R.I.’s one day and musculoskeletal M.R.I.’s the next.”

Dr. Forman says it pays to check the credentials of a center’s radiologists.

“If you say, ‘Who will be reading my scan?’ and they say, ‘One of our radiologists,’ you don’t go to a place like that,” he said. (I checked the Web site of the first center I went to. The radiologist who read my scan was a generalist with no special training.)

It also pays to ask the radiology center whether it has the latest generation of scanners. The stronger the magnet in the MRI machine (the "M" in MRI stands for Magnetic), the higher quality the image it produces.

Misreadings of MRI scans can cause tragic, preventable injuries to patients, as our firm's experience has shown.

The other piece of advice we can extract from the article is not to place absolute faith in a first-time scan that turns out negative. If the scan is negative and you feel that something is still wrong--like there is still severe pain--it is worthwhile to get a second opinion.

Hospitals have long used color-coded bracelets as shorthand to communicate patients' needs to doctors and nurses. For instance, a purple bracelet might indicate that a terminally ill patient does not wish to be resuscitated in the event of heart failure.

Now there is a movement to standardize bracelets, preventing confusion when a health care worker moves from one hospital where (for instance) yellow bracelets mean "do not resuscitate" to another where they indicate an allergy to peanuts.

Bracelets have other pitfalls--for instance, a patient might not wish to advertise a certain desire or condition to visiting loved ones. And children have a tendency to take them off and trade them with each other.

The important thing, if you or a loved one is staying in a hospital, is to know what the colors of your bracelets mean and be prepared to tell doctors and nurses about it. If a doctor or nurse comes up to you or your loved one and begins doing something you don't understand, do not hesitate to ask about it--not only is it good for you to know these things in general, but they may be acting on a misinterpretation of the colored bracelet.

Forbes Magazine has an informative article on the frequency of hospitals making mistakes while caring for patients, pointing out that 1.5 million Americans fall victim to such errors every single year.

Some of these errors occur through sheer carelessness: for example, 100,000 people a year die from "superbugs," bacteria that are resistant to available antibiotics. Infections from these superbugs can frequently be prevented by hand-washing. Yet other errors are the system's fault and not the fault of any individual. They occur because of overcrowding and the consequent inability of doctors and nurses to spend sufficient time with each patient.

The article also cites an Auburn University study showing that hospitals administer the wrong drug one time out of five. The dosage of the drug is another common source of error. A famous recent example of a drug error is from last November when actor Dennis Quaid's newborn twins were given 1,000 times the intended dose of the blood-thinner heparin. Luckily the hospital detected the error before permanent damage was done.

What is the bottom line? There are no magical solutions, especially since most of these problems are systemic. As a doctor quoted in the article says: "If you're sick, the best way to avoid getting sicker is to take charge of your care." Asking questions and being unafraid to make demands is the most any individual patient, or their loved ones, can do to reduce risk of error.

USA Today has published the government's best estimates of death rates due to heart attack, heart failure and pneumonia for every American hospital for the past two years. The article has links to the pages where the death rates are published. As USA Today points out, this information was previously inaccessible to most patients.

From the article:

Now anyone with access to a computer can directly compare a local hospital with the one across town to see how it stacks up against the biggest medical institutions nationwide.

Death rates from heart attack, heart failure and pneumonia are widely viewed as yardsticks of a hospital's overall performance.

Using this resource is one good way that people can get the information they need to make sure their health is in the best hands.

A new study from the journal Quality and Safety in Health Care, and discussed in the NY Times Well blog, reveals common testing mistakes by primary-care doctors. Of course, the same kinds of errors can happen in hospitals and other health care settings.

Out of close to the 1,000 mistakes experienced by 590 patients, the following testing mistakes were the most common:

-13% involved ordering the wrong test or failing to order a test

-18% involved performing the right test, but doing it improperly

-25% involved delays in getting tests back from the laboratory, failure to get the tests back at all, or errors on the results report

-7% involved failing to follow up with patients after receiving results from the laboratory

-75% of the mistakes caused the patient to suffer (through delays in proper treatment, greater expense, physical pain or worsened overall health).

What can a patient do about this? A possible solution would be to carefully ask and write down what specific test your doctor has ordered for you. Ask when the results of the test are expected from the lab. Then make sure you call to follow up after the doctor's office should have received the results. Read the results report, if you can get hold of it, to see the name of the test and make sure that the results are for the same test that was ordered and performed. All of these things might help reduce your risk. Calling the doctor to follow up is probably the most important item on the list, as Dr. Lamberts says in his quotation in the linked NY Times blog post.

Starting October 1, 2008, Medicare will no longer pay for eight hospital-acquired conditions that could be prevented if hospitals followed the proper guidelines.

Those eight conditions are bed sores, objects left inside the patient during surgery, falls that occur when the patient is in the hospital, blood incompatibility, air embolism, mediastinitis (infection of the area between the lungs, which can happen after a heart bypass surgery), catheter-associated urinary tract infections, and certain bloodstream infections. In addition, several other conditions have been proposed as additions to the list.

The purpose of this change is to provide an incentive for hospitals and health care providers to avoid errors and prevent neglect of patients. If both Medicare and the patient refuse to pay for treatment of a hospital-acquired condition, then the hospital is stuck with the costs, and most hospitals would obviously wish to avoid that.

This is a long-overdue incentive for hospitals to reduce the incidence of these events and injuries which should never happen.

Laura Landro, in her column "The Informed Patient," discusses the problem of adults neglecting to get vaccinated for new illnesses. Not only that, but adults forget or are unaware that some childhood vaccinations lose efficacy after some time and need to be re-done. Skipping pre-travel vaccinations is also a common error.

Part of the problem is insurance: not only is vaccination for the very young more likely to be encouraged, but it is also more likely to be covered by insurance providers.

The whole column is worth a read, but here are some disturbing statistics Landro cites:

-only 2.1% of adults are vaccinated for tetanus, diphtheria and whooping cough, despite the existence of a combination vaccine for all three.

-only 1.9% of adults have been vaccinated for shingles. The shingles vaccine is recommended for all adults over 60.

-only 10% of women from 18 to 26 have received the vaccine for human papillomavirus, which can lead to cervical cancer, and which most insurance providers will cover.

A recent New York Times article discusses how doctors, patients and lawyers are discovering that apologizing for medical errors often helps both doctor and patient. The patient gets closure and a sense of acknowledgment, and will receive a settlement more quickly. The doctor does not have to suffer the psychological pressure of denying any wrongdoing or cutting off contact with the patient and can avoid a lawsuit.

As the article notes, conventional wisdom has long held that a doctor should say absolutely nothing in the event of a medical error. Disclosure, it was believed, would only make the doctor and the hospital liable. But empirical evidence suggests otherwise:

Despite some projections that disclosure would prompt a flood of lawsuits, hospitals are reporting decreases in their caseloads and savings in legal costs. Malpractice premiums have declined in some instances, though market forces may be partly responsible.

At the University of Michigan Health System, one of the first to experiment with full disclosure, existing claims and lawsuits dropped to 83 in August 2007 from 262 in August 2001, said Richard C. Boothman, the medical center’s chief risk officer.

“Improving patient safety and patient communication is more likely to cure the malpractice crisis than defensiveness and denial,” Mr. Boothman said.

What most patients want in these cases is not the largest settlement possible but some sort of acknowledgment, honesty and respect. And doctors, hospitals and patients all want to settle these matters quickly without long, drawn-out courtroom battles. Full disclosure policies are a promising new way of achieving these goals.

Christina Laun at RN Central has made a helpful list: 25 Tips to Help Protect Yourself from Medical Errors.

Reading the entire list is a good idea. But many of the items on the list can be boiled down to two principles: 1) be an active participant, and 2) don't be afraid to seem entitled or pushy in demanding knowledge of what is going on. Don't be afraid you're annoying your doctor by asking questions, for instance. Speak to every member of your surgery team and make sure they know what they're doing--do not simply trust, and remember that there is no reason to feel ashamed or embarrassed about asking questions.

Furthermore, bring family or friends to support you, if you can. If you're ill, you may not be able to do the things on the list yourself. Having someone to ask the questions you don't think of and notice the things that you don't notice is an invaluable asset.

Vesna Jaksic has an interesting article on Law.com on potential problems with binding arbitration agreements between doctors and patients, wherein patients sign away their right to a jury trial.

From the article:

Binding arbitration agreements between doctors and patients -- in which patients waive their right to a jury trial -- are becoming more common, a trend that could put patients at a disadvantage if medical malpractice disputes surface, attorneys warn.

A growing number of physicians, nursing homes and health care institutions are asking consumers to sign these agreements before offering services, said Stuart Ratzan of Miami's Ratzan & Rubio.

Some states have passed or are trying to pass legislation that would limit how these agreements are used. For instance, an act waiting for congressional approval in Washington D.C. would require (among other things) that the costs associated with arbitration be disclosed in the arbitration agreement. This is important because the patient must pay for arbitrators to do their job, whereas they do not have to pay for judges and juries.

It would be particularly disturbing if these agreements became common enough that people cannot get medical care without signing one.

Tara Parker-Pope has an interesting interview with Dr. Gary Brandeland about how doctors deal with medical mistakes. Dr. Brandeland's obstetrical patient died due to someone else's error, but Dr. Brandeland still suffered from guilt over it. In addition to the interview with Ms. Parker-Pope, he has an essay describing the incident.

One of Dr. Brandeland's insightful comments is that mistakes tend to be more systemic than individual: nursing shortages and hospitals cutting back on staff to cut costs are factors that lead to overworked or confused nurses, which in turn lead to medical errors.

A depressed medical resident is six times more likely to make a medication error than one who is not depressed, according to a new study published in the British Medical Journal.

The study's findings are not absolutely conclusive, as the authors note. But the common problem of medication errors is often correctly attributed to the brutal schedule imposed on most medical residents. The authors advocate further study of doctors' working conditions with an eye to improving them.

Doctors are unwilling to report colleagues for making medical mistakes, as we have discussed before. A new study from the University of Iowa shows that a significant number do not report their own, either, even though they believe they should.

Lauris Kaldijan, lead researcher for the study, had this to say about it:

Kaldjian said in an interview that he was encouraged that most of the doctors believed reporting errors was an important way to improve health care quality. But he said he was troubled by the fact that fewer than half of them would have reported the hypothetical error if it didn't cause problems. He said doctors and other medical workers should take their cue from the airline industry, which encourages pilots to report every error so it can be analyzed for possible systemic flaws.

As the linked article notes, there are several positive aspects to this study. For instance, awareness of the problems caused by medical error has increased, and belief that errors should be reported is strong.

Out of nineteen industrialized nations, the U.S. has the most deaths that could have been prevented by access to timely, effective medical care.

Ellen Nolte and Martin McKee of the London School of Hygiene and Tropical Medicine performed the study, looking at deaths before the age of seventy-five caused by numerous diseases and complications. They found that France performed the best by this measure--though France, and other countries that ranked higher than the U.S., spends less money on health care than the U.S. does.

Not only was the U.S. the worst in these rankings, but we Americans are also ranked four places lower than we were in the last study (which covered 1997 and 1998). We are getting worse and spending more money.

Guilt, fear, and further isolation plague families of victims of medical error, says the New England Journal of Medicine.

Why guilt? Because families feel like they should have kept a closer watch on their loved one, and regret the trust they placed in the health care institution or its workers. This guilt persists even if the family took reasonable precautions--for instance, the authors of the article discuss a case where a patient was given morphine and died of kidney failure despite the fact that his family repeatedly told doctors and nurses that he had sickle cell anemia. The family often feels inadequate for being unable to watch the patient twenty-four hours a day.

They also feel fear: fear of retribution, fear that health care workers will neglect or compromise their loved one's care if they make some sort of formal complaint. This is particularly true of people in disadvantaged and disempowered sections of society.

Their emotional turmoil is often compounded by the reactions of the health care workers, who will often isolate the patient's family after realizing their error. This leads to further pain and may even lead to further medical mistakes:

Guilt persists in the daughter of a woman who died after a series of errors culminating in a missed case of pneumonia. Although the daughter is a nurse, she could not gain entry into her mother's circle of clinicians, who closed ranks after the errors occurred. "The nurses were ruder to me than you can ever imagine, and the doctors wouldn't tell me anything," she said. "They looked at me like I was a dumb little girl. I became so addled that I couldn't act decisively and get her out of there to another hospital. I'll never get over my guilt."

This isolation comes at a time when, as the authors point out, patients most need someone to communicate with them on a personal and human level. They suggest that honest, direct communication--without condescension, buck-passing or hedging around to avoid lawsuits--is the best way to keep the patient safe as well as feeling satisfied with the care he or she has received.

A new study shows that although an overwhelming majority of doctors believe they should report colleagues who make serious medical errors or otherwise violate professional standards, most do not actually do so.

This hesitance to report colleagues is understandable. But it makes detecting, tracking and studying medical error very difficult.

The senior author of the study, Dr. David Blumenthal, says that he is optimistic because most doctors support existing standards and the lack of report is not due to disagreement over ethical obligations. He also notes that doctors who practice in groups of three or more are more likely to report than other doctors.

Another interesting result of the study is that one-third of doctors admit that they would order an unnecessary MRI. Given the costs and the possible side-effects of unnecessary testing, this fact may have consequences.

Rhode Island Hospital has, for the third time this year, done a brain surgery on the wrong side of the patient's head.

The hospital has been fined $50,000 and has received a reprimand from the state Department of Health. In this most recent instance, the patient was 82 years old. Fortunately, the patient was unhurt by the mistake. However, in one of the previous instances of this mistake at this hospital, the patient died as a result.

Rhode Island Hospital has said that it will be conducting a review of its procedures and implementing reforms. One such reform would be to allow nurses greater power in ensuring that procedures are followed correctly. Another would be to mandate better verification of surgery plans, which would require better communication between surgeons and other doctors. These reforms highlight a major factor in averting medical errors: teamwork. The multiple healthcare professionals involved in taking care of a patient need to be empowered to speak up if they see something going wrong. They also need to know what the others are doing, and to make sure that they are not acting contrary to the recommendations and instructions of other healthcare providers. Performing a surgery on the wrong side of the head is only one possible thing that could go wrong in the absence of communication. Another example would be giving a patient medications that, combined with medicine the patient is already taking, could cause problems. Such errors can be minimized through proper communication between healthcare professionals.

For more information: When Surgeons Cut the Wrong Body Part

Imagine having to go to the hospital tomorrow for a procedure that the doctors tell you is simple and practically risk-free. You’re not worried. Your loved ones are not worried.

The trouble is, the procedure ends up killing you. Through some mistake or miscommunication or broken link in the healthcare system, you die while receiving what ought to be a low-risk medical treatment.

This scenario is not nearly as uncommon as it should be. However, there is a rising tide of activism and reform coming from those who suffer such incidents. Consumers Advancing Patient Safety (CAPS) is one of the many groups involved in such work. Among their other activities, they invite those who have suffered through breakdowns in the healthcare system to share their stories with CAPS so they can reach a wider audience and help each other to understand that what happened to them was not a fluke but an indication of systemic flaws.

The most recent such story CAPS has published is an interview with Helen Haskell, who in 2000 lost her 15-year-old son Lewis Blackman to a medical error caused by an inappropriate medication given during a relatively routine surgery.

The chief point to take away from Helen Haskell’s story is that there are multiple levels of doctors in a hospital. Lewis was mostly treated by residents, who are fully trained doctors in the sense that they have graduated from medical school, but are still considered in training for whatever specialty they have chosen. Care by residents is standard and safe—but when Helen wanted to speak to a more senior doctor, she was unable to do so. Hospital bureaucracy can get in the way of patients getting the information they need. In addition, patients can often get confused about who is treating them and at what level of training that person is: is he or she a nurse, or a medical student, or a resident, or an intern, or a fellow? It is not always easy to tell.

Another key point is the concept of “rapid response teams” that can be called in if a patient or family member believes that something seriously wrong is happening. Helen Haskell believes such a team would certainly have saved her son’s life. In any case, it would give patients recourse if their concerns are ignored.

Patients often want to know what they can do for themselves to prevent medical errors. Often they feel helpless, ignorant and confused when they are seeking health care.

Thanks in part to the Internet, there are now sources that remedy this situation by providing information and helpful suggestions. Many of these various suggestions boil down to certain basic principles.

One crucial thing is to make sure each of your healthcare providers knows what you've told the other ones and what they are doing to you. Your primary care physician should know what you've told your specialists and what those specialists are prescribing for you. Each specialist should know what every other specialist is prescribing for you, and the reasons for this, and what your state of health is in general. This way, the doctor prescribing something for your leg won't accidentally give you something that could harm your heart or that you might be allergic to.

Another important general principle to keep in mind is not to be afraid to ask questions. Ask about what exactly your medications will do, if there are any alternative treatments, if there are any side effects, or about anything else that strikes you as important to know. Ask if anything confuses you about how long you should be taking a certain medication, or how often, or what activities might or might not be acceptable while you are taking it.

Do not worry about annoying your doctor or sounding stupid. Your doctor is there to look after your health and to help you understand what you should be doing, not simply to give you orders. Asking questions becomes doubly important when you are staying in a hospital. Do not hesitate to question nurses and other caregivers about what exactly is happening with regards to your care.

Another good thing to do is take advantage of all the information that is available to you in books, in magazines and on the Internet. Through these sources you can find expert answers to many questions--though these do not substitute for the attention of a medical professional.

Other places to find information on this: The Family Doctor, Medical Errors: Tips to Help Prevent Them.