God's Work

...Bringing us to the AMA...

...But this only estranges people who aren't blameworthy and further compli- cates the system, guaranteeing more, not fewer errors at the sharp end...

...On the contrary, there was more than one unsympathetic allusion to the plaintifflawyers and the media...

...Grant is a Colorado district attorney...

...They have long generated hundreds of thousands of casu- alties anually in American hospitals large and small, famous and obscure, urban, suburban and rural...

...Just this -that the medical profession and the so-called healthcare industry have started discussing ANEs in public...

...The American Spectator • February z999 local resident Walter Annenberg has a nine-hole course of his own--that hundreds of doctors, pharmacists, nurses, statisti- cians, HMO types, hospital and insurance CEOs, human fac- tors engineers, cognitive psychologists and so on from the U.S., Canada, Europe, and Israel gathered for the second biennial Annenberg Conference...

...His listeners, including many nurses, smiled tightly, for in 1996, after three nurses gave one-day-old Miquel the wrong medication and he died, Grant indicted them...

...Though not a union, it always looked out for the interests of doc- tors, by no means excluding their financial interests, and in its prime the AMA was second to no lobby--not the NRA, not the school teachers, not the AARP, not the friends of Israel, not Tobac- co-at throwing the fear of God into politicians...

...A lawsuit filed by the Sunbeam Corpo- ration against the AMA was to go to trial days before Annenberg II...

...So much for the good news...

...Just about the only heretic invited by the organizers of Annenberg II to speak, he wasn't repentant...

...One was acquitted, two pleaded guilty to criminal negligence, none went to jail, but the case shook the nursing, doctoring, and hospital-administrating worlds and made him extremely unpopular...

...The way to enhance patient safety and reduce errors is "to redesign our systems to make errors difficult to commit and cre- ate a culture in which the existence of risk is acknowledged and injury prevention recognized as every- one's responsibility...

...One reason is economic--the market no longer is controlled by doctors who treat and charge as they like but is run by insurance companies for which they labor...

...Though the AMA is still among the big players, it doesn't auto- matieally get what it hankers for or stop what it loathes...

...he hostility of the question period gave an inkling of the context, the unseen history, the second story as it were behind the Annenberg Conferences, the National Patient Safety Foundation, and this hole discussion of"errors...

...Instead of"negligence," you hear "maloccurrence," "therapeutic misadventure," "unex- pected outcome," "mishap...

...But times change...

...We're talking of an Adverse Negligent Event, a medical screw-up that could have been prevented...

...Atoken of how far in the world this unique profession has slipped are moves by doctors to organize for collective bargaining, anti-trust laws or no anti-trust laws...

...An editorial one week before in the AMA journal, known officially as ]A/V/A, had put the message and the faith in a nutshell...

...Admittedly, the N-word is rarely used...

...It didn't take studies to open their eyes...

...Miquel died, he said, because standards were gross- ly deviated from by certain people...

...What then is the news...

...The .~ bad news is that if you re a conservative, neoconser- d ~vative, or libertarian, the odds are exactly the same...

...So do the scandals...

...The favorite, the buzzword, is "error," as in the motto of a recent three-day get-together in Ran- cho Mirage, California, organized by the American Association for the Advancement of Science, the Veterans Administration, the Joint Commission on Accreditation of Healthcare Organiza- tions, and mainly by the American Medical Association's Nation- al Patient Safety Foundation: "Enhancing Patient Safety and Reducing Errors in Health Care...

...Indeed, Annenberg II unmistakably had something about it of a revival meeting...

...But though excessive mistrust isn't healthy, the depressing fact is that in the last quarter-century, the AMA, like most of the profession it once had a better claim to represent, has logged a mediocre record on quality and safety, and like the pro- fession has only bestirred itself when plaintifflawyers and muck- raking, liberal reporters forced it to...

...Richard Cook, a bow tie-wearing Chicagoan on the board of the National Patient Safety Founda- tion...

...Anyway, historians will probably say the AMA began losing it in the mid- 6o's, when it declared, fought, and lost its war on Medicare...

...Yet it was a debate on the judicial aftermath of the short life of Miquel Angel Sanchez which flooded a crowded auditorium with less pleasant, arguably more illuminating emotions...

...Cook's speech was the best-received...

...Meals were taken in a big tent pitched next door...

...You heard it as often as "error" in the many lectures, panels, and break-out groups ofAnnenberg II...

...Sunbeam complained that having undertaken to endorse its products, the AMA pulled out when the media raised a fuss...

...Yet instead of growing, the sovereignty of the pro- fession has been dribbling away...

...But the hit was Dr...

...Likewise, the anes- thesiologists kicked offtheir patient safety foundation, and did improve their very risky systems, only after a "2o/20" expos4 of preventable, negligent deaths on the operating table...

...He spoke with passion, an anesthesiologist himself, even though it was his specialty that first went in for patient safety in the 198o's by designing fail-safe equipment with lights and buzzers...

...Furthermore, no study has yet entered the unexplored territory of outpatient clinics and doctors' private offices...

...Lundberg believes is neces- sary to hoist and keep those in-office gold mines up to clinically reliable standards...

...Normally today, he said, when errors happen and get superficially investigated, the upshot is merely that someone is blamed and new mles may be introduced...

...The California, New York, Utah, and Colorado studies into Adverse Negligent Events were only commissioned as reac- tions to what the AMA and the state medical societies deemed an epidemic of frivolous malpractice suits...

...System" is another buzzword...

...Getting the wrong dose of medication, getting someone else's medication, being anesthetized by someone who's asleep him- self, getting the wrong limb operated on if not removed, being the victim of misdiagnosis or the bungled use of new-fangled or tried-and-true machinery--all such events can leave you hurt or dead...

...In a way, it's not even news...

...Dr...

...44 February I999 " The American Spectator...

...For behind the "first story" discovered by an ordinary investigation must lurk a "second story" to do with the "hidden vulnerabilities and strengths and dynamic character of the system...

...David Gaba of Stanford, if anesthesiol- ogists, ER interns and others are dead on their feet, and if this gives rise to errors, it's not their fault but that of hospital and departmental systems that drive them with impossible, combat-like work loads...

...A set- tlement of $9.9 million kept Annenberg II from having to com- pete with news of the trial...

...No one spoke of this into a microphone in Rancho Mirage...

...Many variations were played on the systems theme at Annen- berg II...

...It's a way, a routine, a practice of doing things which either minimizes or maximizes the chances of their being done right and the essence of which is imperson- ality-a risky system like the one in which Medication X and Medication Y are stocked in identically shaped, iden- tically colored bottles has no human face, no first and last name, and neither does a less risky one in which these med- ications are cunningly stocked in bot- tles more difficult to mix up...

...Never have there been so many doctors in the U.S., never have they possessed such miraculous tools of diagnosis and therapy, but you'd have to go back several genera- tions to finda time when they had so little clout or self-respect...

...And more than one AMA person told me one-on-one with the same frankness that their National Patient Safety Founda- tion, progenitor of Annenberg I, Annenberg II, and Annen- bergs to come, would never have been thought of but for the Lehman horror story and an eruption of others...

...What's a system...

...Three-fourths of all doctors belonged to it then, down to one-third now, mainly on the wrong side of 50, and the membership and demographic figures get around...

...A new under- standing of accountability that moves beyond blaming individuals when they make mistakes must be established if progress is to be made...

...Very good...

...By now, the only skeptics are those who believe these figures are too low because they're drawn from medical charts, and usually such charts, to put it kindly, are impressionistic...

...Good...

...Perhaps lobbies in general aren't what they used to be...

...A revolutionary new approach is needed to break the cycle...

...One should never be too mistrustful...

...By then, halfa dozen of the associa- tion's executives who'd made the deal had been purged, and Dr...

...Improving systems...

...For example, said Dr...

...Lundberg himself, a pathologist, edits his magazine with fine independence, and has even published research supporting continued regulation of doctors' in-office labs by the government, something that came about following an expos4 in the Wall Street JoumaI, something the AMA hates, and something Dr...

...George Lundberg, editor of JAMA, had written, "The AMA, largely populated by new high-level staffand emboldened by a newly approved Vision, is fleshly energized toward high-quality medical care...

...Only by for- saking the reflex to blame and concentrating on this deeper story can anything be learned and fixed...

...The findings have been uniform: of every hundred patients admitted to hospital, one either dies or is hurt because of sub- standard care...

...Rancho Mirage enjoys probably the world's highest density i of golf courses, and it was at the Annenberg Center there-EDWARD GROSSMAN is writing a book on medical malpractice...

...Nor, jumping into a strange bed with Clinton, did it get laws enabling patients to sue HMOs for the same cause of action...

...Over a low-fat breakfast in the tent, someone from the Joint Commission on Accreditation of Healthcare Orga- nizations- the outfit hospitals pay to check up on them--told me that after 4 ° years in business, the JG only came out with its "Sentinel Event" program after the media featured the story of Betsy Lehman, a 39-year-old health reporter for the Boston Globe who died in 1995 from numerous chemotherapy over- doses...

...First in California in the 197o's, then in NewYork in the 8o's, now in Col- orado and Utah, teams of experts have been subsidized with tax and foundation money to pore over records and discover how often ANEs happened in each state...

...To a jam-packed, riveted, grateful audience, he delivered a lecture with slides illustrating how errors of all kinds happening at the "sharp end" of a system--in medicine, where doctor or nurse or technician meets patient--are really caused by the unseen "blunt end" of the system bearing down with its "policies, procedures and constraints...

...Doctors and nurses, and their fam- ilies and best friends, have always known that hospitals, yes, medicine in general, can be hazardous to your health...

...I feel," said Robert Grant, "like the anti-Christ at a revival meeting...

...He'd do it again...

...There's also such a thing as personal responsibility, and when it's set at naught as it was here, a DA's responsibility is to prosecute...

...For the lastgeneration, American medicine has continuous- ly been acquiring wonderful new ways to detect, prevent, treat, and cure disease...

...For example, in bed with the Republicans, it couldn't get federal tort reform to hinder patients suing doctors for malprac- tice...

...Yet one-on-one candor wasn't unknown...

...The gospel preached at Rancho Mirage holds that virtually all the errors hurting and killing patients day and night from coast to coast are due to such mix-ups, to a flawed sys- tem that caused them to happen rather than to anyone's laziness, incompetence, recklessness, inexperience, senility, or negligence...

...This being America, however, studies there were...

...But this wasn't a systems failure...