Medical Errors Report: October 31, 2003

Book: Managing Crises on the Job – An Interminable Journey to Fixing Medical Errors by 'Yinka Vidal, published by Lara Publications, due for release summer, 2004

Summary Report: Report by 'Yinka Vidal

Report of a 27-Year Observational Study on Medical Errors and Systemic Failures Within the Health-care System

A Four-year Solution Implementation Study   

 Introduction

 I declared war on medical errors in 1977 while a graduate student at Washington University School of Medicine. My earlier objective was finding the cure for cancer through monoclonal antibody since some of the cancer chemotherapeutic agents were themselves causing cancer while others were causing serious suppression of the bone marrow among other serious side effects. My desire to continue that mission melted after I got married, began working two jobs and started living life. But my graduate background helped me to see many of the preventable patient deaths while I was working in various hospital laboratories. Initially, when I was exposed to these mistakes, I was traumatized and unable to sleep for many nights after the incidents. Dealing with human deaths was very troubling to me. The saddest part was not the complexity of the problems leading to many deaths, but the simplicity of those problems.

 The administrative systems were very authoritarian and nobody dared to question what the physicians were doing in the 1970s. I saw patients dying of simple systemic failures, and I was totally helpless. From this time, I became an investigator and started working like an undercover reporter. I was only collecting information. When I saw questionable deaths, I would try to find out the cause by interviewing physicians, nurses or pathologists. I started to collect case stories upon case stories. In 1993, I published the first book, Overcoming the Invisible Crime disguised as an autobiography to avoid criticism by my peers. The book discusses management crises in hospitals for the first time. It also discusses how the problems have affected the quality of patient care. The book also predicted the present crisis of litigation explosion in health-care, the financial implications for the health-care industry and the impact on the quality of patient care.

 In the summer of 1999, my project was transformed from working like an undercover reporter to an active participant in trying to fix medical errors. I started a national study to collect data about solution intervention and why medical errors continue to kill many patients every year. Some health-care executives were beginning to see the problem I was trying to expose. I remained the target of persecution for obvious reasons. Part of the criticism to my first report was the high number of predicted deaths and the impact of management crisis in the health-care industry. In December 1999 a couple of months after I started my second phase of study to find solutions, the Institute of Medicine published a report confirming the alarming number of patient deaths due to medical errors. I was vindicated, but the battle of medical errors was not over; it was just about to begin.

 In 2002, I published the second book, 101 Ways to Prevent Medical Errors - 307 pages, which discusses my quest of working with health-care institutions to find solutions to medical errors. Even though I had been a manager when I wrote the first book, I was not working directly with the hospital administration. I was an outsider looking inside many hospital administrations. At that time, the inner workings of most hospitals remained very mysterious. When I wrote the second book, I was working with the hospital administration, and for the first time in my life, I became an insider able to see the problems of health-care management affecting the process-line of daily operation of patient care. Although the second book discusses many of the barriers encountered as part of the human factor, I was wrongly of the opinion that once the phase of solution-implementation started, the barriers of human factor would disappear. Little did I know that this problem was about to take an uglier turn.

 Late in 2002, I became the chair of a committee working to fix medical errors in a health-care institution in New York under our study. While chairing this committee, I also remained the chair of the National Campaign to Prevent Medical Errors. There are project members in hospitals across the nation contributing to information gathering. We all remained under cover for fear of being discovered and persecuted. Most of the observations in this study are supported by the results of studies done by others and articles written by experts in this field.

 One thing was very clear throughout the four-year study, there were many encounters with fierce emotions that deterred the progress of solution implementation. Initial reaction was to ignore this issue because it was not part of the measuring indicators. But, it did not go away and continued to negatively impact the study. At a point, the force of negative emotions almost ended the study. When we started comparing notes with others in the health-care industry, we noted we were all experiencing similar barriers, though in different states. Very few journal articles have been written about the impact of hyper-emotion affecting the quality of patient care. Many health-care professionals are afraid to discuss the issue, and for many years I ignored the problem. Fortunately, some drastic events forced me to devote a book to this malaise in the health-care industry. Those events gave rise to the book, Managing Crises on the Job – Reported for Working on Duty and Reprimanded for Working Too Hard. This book defines the anatomy of crisis in hospital management better than ever before. The title is not a gimmick; it was created after a series of shocking events that brought so much shame to the profession to which I had dedicated my service for over 30 years. One begins to wonder why should a person be reported for working on duty or why should a worker be reprimanded for working too hard. The answer lies in the mystery of health-care management today and this book cracks open the forbidden door into the management styles of some hospitals. Added to my original intention to find and implement solutions to medical errors was my relentless effort to manage crises within the health-care system. Otherwise, the project was going to stagnate. At a certain point, managing one crisis after another became one of my priorities. The problems created obstacles for improving the quality of patient care.

 This book therefore, identifies many barriers encountered during this phase of solution implementation and gives unequivocal reasons why progress in fixing medical errors continues to be slow. However, the summary report, which preceded the story of the chronicle, is a summation of the solution interventions to date and some highlights from other phases as well. It is important to know that this particular book was never intended, but due to repeated challenges faced during this phase, it was of critical importance to devote a separate book to the topic of “managing crises” within the health-care industry. Emotional crisis is not new in health-care, but it is rarely discussed. Ignoring such a giant problem has now become second nature to many people within the industry. The process of solution implementation was stagnated by problem after problem resulting from resistance at every level of intervention, from frontline workers to top administrative executives within various hospitals under study. The lesson learned from this study will greatly benefit not only health-care institutions, but all other businesses interested in quality improvement and the fixing of systemic failures on the process-line.

 I should caution readers though that you do not have to agree with every observation in this study because one suit does not fit all. Your institution may have different sets of problems from those described here, but you should be able to learn something from each observation and story told here. The stories not only elaborate on the need to improve upon emotional intelligence in health-care, they describe how the quality of patient care is affected by this unspoken problem. The book reports on the deficiencies within the operation of the health-care industry. It suggests ways to redesign processes, fix systemic failures to reduce risks, and make the system more cost effective. One day, you and I may be on the receiving end of medical care. We know we have problems; many people on the outside know we have problems, but some have mistakenly defined these problems as part of the complexity of the system. We can no longer bury our heads in the sand pretending everything is okay. When the narrative part of the story starts, take out your pen and grade the emotional intelligence of each of the characters. In the end, you decide whether health-care workers are working with high emotional intelligence or if they need help in this arena. For many years, I worked with a low level of emotional intelligence despite my academic background that includes two degrees and postgraduate work. A series of very painful and traumatic experiences taught me a good lesson about life. They helped me to develop and improve my own emotional intelligence after 30 years of working in the health-care industry. The next question is, what is emotional intelligence? I will explain this in later chapters.

             Solution Interventions: A Four-Year Summary Report

Before the story-telling part starts, it is important to give a summary of some of our findings in this study. Throughout the four years of study, over 2,000 nurses were briefly interviewed, 12,000 questionnaires were sent out to hospital executives and close to 200 other hospital workers - - including physicians, lab techs, pharmacists, and X-ray techs - - were interviewed. A lot of valuable information was collected over the course of the study and some of them are still being tabulated. There are certain issues that stood out more than others while trying to fix errors or systemic failures.

 The process of fixing medical errors, involves about six different phases depending on the institution. These include identification of problem; root cause analysis; solution design; solution implementation phase; result measurement; and follow-up study. The details of the entire process will be discussed in the final report, Process Redesign – An Effective Way of Fixing Medical Errors and Systemic Failures. It is important to understand that this report comes from four years of working to fix medical errors and the larger part is devoted to the solution-implementation phase. In this report, the issue is no longer about medical errors; the primary problem centers on the management of crises in health-care institutions and the obstacles created for the war on medical errors.

 After the IOM report in December 1999, many organizations and institutions sprang to action; they were all interested in fixing medical errors. Our national project was doing the same thing, working directly with those health-care workers at the frontline of operation. Most people in health-care management are very detached from those doing the work. After four years of relentless work, many were concerned about the slow progress in fixing medical errors. Although many errors happen every day in hospitals across the nation, nothing grabbed the public’s attention like the death of Jesica Santillian from Duke University Medical Center, one of the leading health-care institutions in the nation in February 2003. Jesica’s death was caused by a simple systemic failure and a lack of effective checks and balances to catch the problem before impacting the patient.

 When 101 Ways to Prevent Medical Errors was published in 2002, a case similar to that of Jesica was cited as an example of a dangerous practice within hospital laboratories that could lead to a patient death. On Page 139 of the report is the discussion of the possibility of a patient receiving the wrong directed donor blood type. There was an outcry calling for this procedure to be fixed to avoid future deaths of patients. A year after the release of the report, despite the elaborate publicity, exactly the same incident warned about in the book happened, leading to Jesica Santillian’s death. I was very devastated! But nobody listened.

 Current research projects on medical errors, results from our study, and my experience of working on solution implementation demonstrate that many management problems besiege the health-care industry today. These management problems are the major deterrent to the progress in fixing medical errors or any systemic failure. The problem has created a giant economic loss of billions of dollars annually due to waste, duplication of procedures, misadventures, medical errors, redundancies, the cost of fixing errors, and so on.