Patient Care

Article on Anniversary of Medical Errors Report Missed Key Points


 

Donald Berwick, MD, MPP, FRCP, is honest, forthright, and accurate, as always. Christine Cassel, MD, is correct: We need to change the culture in medical school. However, diagnostic errors aren’t “emerging” as a medical error—they’ve been with us all along.

I would point to Maureen Thiel as one example. She was the victim of repeated diagnostic errors in the late 1990s. Her widower, Bill Thiel, has been a patient-safety advocate ever since (www.maureensmission.org).

“Failure to rescue” is an emerging medical error. Lori Nerbonne of New Hampshire Patient Voices has a story of a failure to rescue that ultimately took her mother’s life.

Lewis Blackman, a healthy 15-year-old boy, died in 2000. He slowly bled to death over the course of several days after being admitted to the hospital for an elective procedure. I’m sure his mother, Helen Haskell, can share his story. She is the director of the Empowered Patient Coalition. You can find her and other advocates listed at www.empoweredpatientcoalition.org/patient-advocate-directory.

What’s missing from your November cover story, “Medical Mistakes, 10 Years Post-Op,” and the accompanying timeline is what really sparked the patient-safety movement. It was the 100,000 Lives Campaign in tandem with medical-error victims and their families. Unfortunately, those numbers have grown exponentially in recent years.

With the exception of Dr. Berwick and Johns Hopkins, our nation’s political and healthcare “leaders” have not taken the initiative with patient safety. And make no mistake: They have been pushed.

Dr. Berwick is leading. We are pushing.

“To Err is Human—To Delay is Deadly” is the message patient-safety advocates took to Washington on Nov. 17, 2009. We think the IOM report should be acted on before it’s commemorated. It should not be a surprise that patient-safety advocates were excluded from this article. We have been dismissed and ignored by the medical profession for years. Why is that? History should not overlook the substantial contribution made by the grassroots advocates.

Lisa Lindell,

Webster, Texas

Author, PULSE of America

Coalition state coordinator

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