Comments of the People’s Medical Society

Before the National Summit on Medical Errors and Patient Safety

Agency for Healthcare Research and Quality

Washington, DC

September 11, 2000

Medical errors and patient safety have been a concern of the People’s Medical Society since its founding in 1983. We were one of the first healthcare groups to warn medical consumers about "nosocomial" infections and "iatrogenic" problems. In August 1983, we told consumers about the incidence, cost and risk of nosocomial infections. At that time, we warned that some 50,000 to 100,000 hospital deaths could be attributed to nosocomial infections. Not only was this a tremendous cost in human terms, but in dollars as well. Nosocomial infections led to longer hospital stays and the use of additional hospital resources resulting in monetary expenses of more than $1 billion annually. Many of these infections could have been prevented if medical personnel had practiced proper hand washing techniques or maintained proper sterility of medical devices, particularly catheters.

Just a few short months later, we again alerted medical consumers to "iatrogenic" or "doctor-caused" illnesses. We pointed-out that there is no such thing as "minor" surgery. Every procedure carries certain risks. Whether it be from anesthesia or the slip of a scalpel, there is always the chance that something will go wrong. However, our purpose was not to alarm. Indeed, our goal to alert consumers that they need specific information before agreeing to medical procedures. They need to be fully informed about the treatment or procedure in order to make an intelligent and beneficial medical decision. They need to know the risks associated with the treatment or procedure and they need to know how often their doctor has performed this procedure. Consumers should also be informed of the most common complications associated with the procedure or treatment and how likely such complications may be given the individual consumers current state of health.

Our efforts to alert the public to dangers inherent in the medical delivery system weren’t limited to the telling of horror stories. The People’s Medical Society is not about "horror" stories; rather, we are about informing patients so they can make knowledgeable decisions and take a more active role in their care. In early 1984 we provided consumers with information on how they could help prevent medical errors. We told them they had to a) know what is being done to them and b) know why it is being done. This alone promotes communication between a consumer and his/her medical practitioner. We recognize that consumers can have an influence on how they receive services just by being better informed and speaking up for themselves or having an advocate with them if they are unable to effectively communicate in their own behalf.

However, it wasn’t until we published best selling book Medicine on Trial in 1988 that the public got its first look at the appalling state of medical care. We examined the medical literature and reviewed the major studies on medical errors. We reviewed what learned physicians were writing about medical errors and how often they occur. We were startled to learn that the literature was widespread and deep on the subject, painting a picture of a health care system that was poorly regulated and, quite possibly, out of control. And, yet, the public was completely unaware of the level of medical mediocrity and the lack of oversight of the system. We also learned where errors were most likely to occur and the circumstances that permitted them to happen. However, what was most disturbing, was the fact that consumers were never told something went wrong. It was as though a wall of silence had been erected around the practitioner and the facility.

On rare occasion, when a medical error occurred a consumer might be informed. But even then it was watered-down and trivialized with statements such as "Don’t worry, this happens to everyone." Of course, it not only did not happen to everyone, but when it did happen it often had dire consequences.

Too often, medical professionals held, and still hold, the view that it is not wise or necessary to inform consumers about medical errors. This arrogance stems from a professional knows best mentality, a mentality that seems to linger in the medical professionals as it fades among most other professions. But the fact is consumers, customers of medical professionals have a right to be informed when something goes wrong. Consumers usually know when a medical procedure or treatment has been bungled. They may not know the particulars or the depth of the problem but they know something isn’t right. The following excerpt from our book Medicine on Trial sums up the situation surrounding medical errors and, remember, this was written some 12 years ago: "Public misgivings continue to rise. But it has not been easy for people to grasp the full story; to know the extent of the problem everyone faces; to appreciate that one news story or one family member injured by medical care is not an isolated event. It has not been easy to get to the bottom of what causes medical mistakes and why precious little has been done to stop them from occurring. The time has come to pull the curtain back and get a clear view, as harsh and alarming as this may be."

Medicine on Trial not only revealed previously unavailable facts on medical errors, but it also offered a plan for reducing their incidence. For the People’s Medical Society, the key issue is the full disclosure of outcome data on every medical procedure by facility and practitioner. We believe that a blueprint for accomplishing this objective can be found by examining how the Pennsylvania Health Care Cost Containment Council goes about collecting and reporting health care utilization data to the public.

We have examined the various proposals for dealing with issue of medical errors and found them to be wanting. While we recognize the need to find a system that works best, we believe any system that doesn’t require mandatory reporting is doomed to failure. As we stated so emphatically in Medicine on Trial, we seek reform, not penalty. We aren’t about finger pointing; however, we won’t sit idly by and watch consumers become victims of a system that should be about helping them. Voluntary reporting simply won’t work. We need mandatory full outcome reporting if we are to discover where errors are most likely to occur and take actions to correct the situation.

We ask this esteemed panel to carefully consider the consumer in your deliberations and recommend a course of action that not only reduces medical errors, but also recognizes that consumer have the right to be fully informed about the outcome of all medical procedures.

In order to achieve the goal of reducing medical errors and improving patient safety, we recommend the following course of action:

>Increased, and strictly enforced, treatment and discipline of impaired physicians and medical care workers.

>Tougher Food and Drug Administration regulations and oversight of present and emergent medical technologies.

>Stricter hospital, physician office and free-standing medical center cleanliness rules and more effective surveillance programs in the fight against nosocomial infections

>The institution of unit-dose pharmaceutical distribution in all hospitals along with automated ordering and fulfillment systems.

>Periodic testing, relicensing and recertification of physicians and other medical care workers

>The creation of medical "teams" in which the physician is not the head or the sole arbiter, but an equal member in a diagnostic/therapeutic group that includes continuous involvement by, and input from, nurses, pharmacists and, of course, the consumer

In addition, we recommend the following with regard to facilities:

>All hospitals or health care institutions must provide an annual report, available to the public, which includes the following information:

>Incidence and outcomes of surgical and other diagnostic measurers and treatments, including, but not limited to:

>caesarian section rate

>lumbar punctures

>prostatectomies

>hysterectomies

>percentage of pathology reports that indicate normal tissue was removed in surgery

>nosocomial infection rate by service--medical, surgery, obstetrics, ICU, etc.

>number of iatrogenic incidents by service and provider

>number and types of malpractice claims filed, decided or settled against a hospital in the past year listing the names of physicians or hospital staff

>morbidity and mortality statistics by service

>a list of tests done routinely on admissions, such as chest x-rays, blood tests and so forth

>a list of names and addresses of the members of the board of trustees, the chief administrator of the hospital and the chief medical officer of the hospital

The goal of these measures is to ensure that consumers will receive the highest quality of care in a setting where the possibility of medical errors has been reduced to its lowest mathematical factor. The significance of these remedies is a system that not only reduces medical errors, but addresses situations where they might arise. No longer should practitioners be permitted to hide behind the veil of confidentiality of peer review when the lives of consumers are on the line. These measures not only benefit consumers, but they also benefit medical professionals by rebuilding that bond of trust that once existed between medical professionals and consumers.

Thank you for accepting our comments on this most important issue.

Media contact information: cbi@peoplesmed.org