From the daily frontline battle of those taking care of patients

Message to Hospital Managers and Fellow Health Care Professionals

A National Campaign to Prevent Medical Errors

While I was working in hospitals and research laboratories, I encountered many systemic problems which adversely affected patient care. At that time, it was not easy to bring attention to the problems let alone work to fix them. Today, things have changed and we have now realized the importance of  solving systemic problems. An effective working system is very crucial to the improvement of patient care. Solving systemic problems has been known to help hospitals reduce waste, make the system more efficient and for the most part, help to reduce cost. The hospital administrators or CEOs cannot be at different locations within the hospital at all times. It is essential that the roles played by managers in problem solving determine the outcome of error reduction intervention within various hospitals. This national campaign to reduce medical errors has four branches. First, to energize medical error reduction and continuous improvement of the quality of patient care across the nation. Second, requesting the U.S. Congress to grant protection to health care workers from criminal prosecution due to medical errors. Third, requesting the U.S. Congress to pass the bill to protect institutions from legal action due to disclosure of medical errors. Fourth, to motivate hospitals across the nation to take active and continuous actions in the prevention of medical errors.

CAUTION: All members of the hospital medical staff should pay careful attention to the issues of prosecution discussed below, this is a dangerous issue that cannot be ignored by any practicing physician.

Should we Send Physicians to Jail for Medical Errors? Should we Send Hospital Administrators to Jail for Inadequate Staffing? Should a Physician Face the Death Penalty When a Patient Overdoses on Medications?

Years ago, these were laughable questions to ask. Perhaps nobody thought such a thing would happen in the U.S. Today, it is very frightening because it is happening! When I asked some hospital workers these questions, some of them answered and said, "Absolutely Not." Yet, there were some who said, "Yes, Indeed." Most workers who answered yes were angry at hospital administrators due to staff reduction and the hardship presently endured on the job. Others were angry at physicians because they claimed some of them were too arrogant and sometimes insulting. For whatever reason however, we cannot allow our anger to create a blanket blindness to the dangerous realities unfolding before us. There is presently a national trend underway to imprison health care workers for medical errors especially those associated with hot political issues like late term abortion, partial birth abortion, drug war and euthanasia. Sadly, some of the prosecutions are not motivated by medical errors as they are more related to the prosecutor's political position. Public anger against medical error is therefore being used as a motive behind the desire to punish these health care workers. The action of the prosecutor is easily accepted by the public that is already frightened. Based on news, people are outraged because of too many medical errors being reported. Some said, the hospital administrators are not responding and the only way to get their attention is to start sending them to jail! Others said, society must make medical errors very costly for institutions so they will be forced to take corrective actions to prevent medical errors causing patients to die. Does this trend make any sense whatsoever?

In 1996, Dr. Wolfgang Schug, an emergency room physician was facing 15 years to life in prison (Amednews.com, March 16, 1998). The California Attorney General's office brought a case against Dr. Schug who diagnosed ear infection in an eleven-month old infant after the kid was brought to the emergency room. Following repeated visits to the emergency room and eight hours of treatment, Dr. Schug advised the infant's parents to have the child admitted to a larger hospital 55 miles away for further treatments. The child later died. The cause of death as stated by the coroner was anoxic encephalopathy due to sepsis following ear infection. In August of 1997, the Sheriff's Department came to the emergency room where Dr. Schug was working, handcuffed him and took him to the county jail. He was charged with second degree murder. The trial judge dismissed the case and Dr. Schug was subsequently hit with a multi-million dollar civil malpractice action by the parents of the infant. This case was so unusual because a physician was prosecuted for making a medical decision which he believed was appropriate. How many more physicians are going to be in this type of a situation?

Dr. Biskind was not so lucky, he was convicted for the death of a patient after surgery and facing 12 years in prison in Feb. 2001. In the same case, the administrator, Carol Stuart-Schadoff was also convicted for not preventing the patient's death and was facing a two year prison term. When I interviewed Carol Sowers, the court reporter for the Arizona Republic in August 2001, she indicated that the case of Dr. Biskind was not politically motivated by the anti-abortion movement as I first thought. Even Judge Michael Wilkinson who sentenced Dr. Biskind made a comment that the sentencing was not a political revenge. "We tried to be neutral and non-bias in reporting such a story," said Carol Sowers, the court reporter who covered the case. She emphasized that the case was determined by the jury as that of a gross negligence by Dr. Biskind. He was sentenced to five years in jail. The administrator, Carol Stuart-Schadoff who was convicted of negligent homicide for failing to schedule a registered nurse in the clinic recovery room was sentenced to four years probation. 

In 1995, Dr. David Benjamin was tried and found guilty of murder in the death of a patient after surgery. He was sentenced to 25 years to life in jail for murder (Arizonarepublic.com, Feb. 2001). Dr. Denis Deonarine, a Jupiter physician was charged with first degree murder due to the death of a patient after prescribing the painkiller, OxyContin.  If convicted, he is facing a death penalty or life in prison without parole, (Naplesnews.com, July 29, 2001). Across the nation, there are many health care workers including nurses, physicians, etc facing various criminal charges due to medical errors, and the list keeps growing everyday! Read the complete story and the forces behind the prosecution of health workers for medical errors.

For years, health care workers have not paid attention to what is happening in the public even when faced with dangerous situations. Prosecuting hospital administrators, physicians, nurses, lab managers, etc. due to medical errors and putting them in jail is a dangerous trend that will eventually destroy the quality of health care in the U.S. Truly, we have problems within the health system. The national objective about medical errors across the nation, is to work hard and fix the problem so patients can be protected from preventable harm or death. This can hardly be accomplished in the atmosphere of threats hanging over medical professionals. It is therefore the responsibility of every health care professional to join hands with their co-workers while working hard to reduce medical errors and consequently improve the quality of care for patients. We have no other choice.

When an airplane drops from the sky, God forbid, killing hundreds of passengers, nobody grabs the CEO of the airliner and drags him to jail. So, why grab a hospital administrator or a physician to be jailed due to a patient's accidental death? If the motivation to imprison hospital administrators for medical errors continues, who is going to be prosecuted next, laboratory or nursing directors? How far are we willing to go with this madness? In Aug. 16, 2001, (msnbc.com) two patients died of intracranial hemorrhage at St. Agnes Medical Center in Philadelphia due to incorrect dosage of anticoagulant given to the patients. The error was due to wrong patient results from the hospital laboratory. The incident involved 962 patients between June 4 and July 25, 2001.

In a case of mislabeled specimen, Dr. Thomas Rynalski was given a pathology slide from a patient (Naplesnew.com, May 28, 2001). His diagnosis lead to a two day cancer chemotherapy treatment of the patient. Later it was noticed that the patient had a normal bone marrow and the patient has since died. It was Dr. Rynalski who reported the case to the hospital officials, admitted his fault in the error, launched an internal probe and the reworking of the hospital pathology procedures. Dr. Rynalski was charged by the state investigator for not being careful in making sure he had the correct biopsy slide. The state investigation report showed a disregard for pathology department rules by several people which later led to the medical error. The state is seeking a disciplinary action against Dr. Rynaski for failing to practice medicine with reasonable care and did not keep legible records as defined by hospital rules. Sad as the stories, the appropriate action is not to drag the pathologist, lab manager or the hospital administrator to jail. The urgent action should concentrate on fixing the systemic problems which precluded the detection of the errors before patients were harmed.

101 Ways to Prevent Medical Errors is not a book written by an outsider, it is a book written by one of  the health care workers in direct contact with patients. I spent over 30 years working in the health care industry before writing this book. Yes, we have had our disagreements with the administration regarding how things ought to be in the hospital. We should never lose our professional integrity because of the bitterness of our differences! Imprisoning hospital administrators or physicians for medical errors is the wrong thing to do! Think about it, if they get to your administrator, how far is the prosecutor from you? Continuous improvement of the quality of care cannot be accomplished in the atmosphere of fear and intimidation by the prosecuting attorney. 

Protect your institution by joining the national campaign to prevent medical errors. Start educating your coworkers about medical errors and how they can be prevented. 101 Ways to Prevent Medical Errors offers many wonderful tips to help avoid medical errors and outlines ways to implement solutions. Order your own pre-press copy of this book and place your company's order to attend seminars for the prevention of medical errors in your own institution. See page #12 for the list of hospital seminars and the page #13 for order form. Nobody wants to be imprisoned for somebody else's mistake! Yet, some health care professionals are unaware of the dangerous storm heading their way!  If you ignore to make a decision over a critical issue of medical errors within your own institution or in your department, somebody else will make a choice for you. Such a choice may be unpleasant! For this medical error reduction campaign to be successful, all health care professionals must actively take part in continuous error reduction programs in their respective hospitals. While we continue our mission of caring for patients, we can not ignore some nagging problems on the job. A few of these are worth mentioning here, the rest are discussed in the book

Hospital Revenue: For various reasons, managers have passively opposed actions by hospital administration to increase revenue. The often cited reason is centralized on health care as a mission of mercy but has now turned to a business losing its humanity. The truth is, no business will run successfully for long without generating enough revenue to match expenses. Instead of fighting a change which cannot be reversed, it is time we started working with hospitals to fix the systemic problems in place. Just imagine what would happen to a hospital's viability when hit with a joint action lawsuit leading to billions of dollars awarded to the plaintiff. Perhaps the medical error leading to such a problem could have been averted if one manager took the initiative to identify such a problem before it became a serious threat to patients. Nobody knows how to identify and solve problems more than those who work in direct contact with patients in various departments of the hospital.

In addition to helping to reduce errors, managers should work to reduce cost. Since administrators do not work in various departments, they cannot determine areas where costs can be appropriately reduced without hurting the quality of care. There are many wastes on the department's level that are never seen by the administration. If a manager can work to save money for the hospital by getting rid of wasteful and redundant spending, forceful staff reduction may be less likely. Wastage is the number one leading cause of revenue loss in many health care institutions.

Service Integrity: My usual slogan is; Excellence is never achieved by doing only what is required.  Some workers thought this idea is crazy! Taking paper work home is not only necessary, it is a sure way to get things done. Many times, I experienced project stagnation because a manager refuses to get the work done due to hesitation to take the work home. From my personal sacrifice, I was motivated to write this book because for the first time in my life, I met a hospital official whose power of passion and spirituality shared with employees inspired me to do more to attain excellence (see the tribute section of this book). A manager should set his or her goals and work to achieve them without fear. Set a limit! When you are tired, take off, and take it easy. Most good managers and directors are relentless workers. Usually they work till they hit a road bump. Consequently, a migraine headache hits, followed by the Saturday morning blues which finally slow things down a little. On Monday, the work cycle starts all over again.

Forming an Alliance with Other Departments: Solving systemic problems may require joining hands with other departments and mobilizing workers to do the same. Get rid of territorial defenses. They tend to create obstacles and also kill the motivation to resolve differences.

Remember the spiritual part of your work: One of the most important aspects of work is the satisfaction of doing something enjoyable. Any job can be made enjoyable as long as the inner mindset is programmed that the job is a service to others. The greatest joy is in giving to others and not in receiving.

Appeal to your sense of humor and humility: Be nice to your co-workers and make yourself available for conversation about strategizing solutions. Never present yourself as being better than others because you are the manager. There may be people in your department more qualified for your job than you may think. Respect your coworkers. Show concern for the welfare of your workers. Be humble and know that the job is not about you getting all the compliments to make you feel good about yourself. Give compliments to those who deserve them and be appreciative of other people's work and achievement.

Take a high road and be diplomatic: Sometimes you may be punished for doing something positive for the institution.  This tends to happen when somebody gets mad because your good work makes someone looks bad. Take a higher road and ignore the jealousy from others, you can hug and kiss them, then continue with your work with a smile. Be a principled person and not allow negative emotions to derail your objectives. Yes, you are going to have some bad days, everybody does! Avoid introducing chaos into an orderly system. Resist the hell-raisers' motive. They only bring attention to themselves!

Show leadership and responsibility: As a manager, be a leader by showing the right way. Show responsibility and integrity by your own personal examples to others. Let the power of your office create an opportunity and the illumination to do the right thing for the system and society. Do not abuse others for your own self gratification. After going through a difficult and chaotic day, it is not the work that matters at that time, but the humanity left in you. Yelling at your coworkers no matter the reason will not attain you any professional respect, but a clear hallway to walk through. There will be moments of joy, pain, satisfaction, and dissatisfaction. Never look at obstacles as problems, but as challenges. Perhaps you may never be able to stop some unhappy incidents, but you can learn how to control your reactions to those unpleasant moments. We all have reasons to do everything wrong or do things that are questionable out of anger. But, the right thing is always the easiest thing to do. Yes indeed, a manager can be the master of the destiny of his or her department because the direction always determine the final destination.

Regardless of obstacles, remain committed to the relentless pursuit of excellence. Fear is the enemy of success. Your greatest asset lies in your heart for your dedication to serving others with humility and respect. Your greatest job is service.

Keep your hospital administrators and physicians out of jail so we can all work together to fix the problems of medical errors. Those who dared to do their work with dignity and profound dedication deserve an honor, not a jail time! The best solution to medical errors is the continuous education and re-education of health care workers. See the list of  hospital seminars for the prevention of medical errors. It is highly essential to share this information with other departments of the hospital including;  risk management, nursing, laboratory, pharmacy, education department and the entire medical staff.

V. 'Yinka Vidal, author of 101 Ways to Prevent Medical Errors