|
Worcester Medicine
FROM
THE
EDITOR
R LEGAL
CONSULT
LETTERS TO THE
EDITOR
Every physician bears the ethical responsibility to
prevent errors and report them. Dr. J. Leonard Morse strongly believed this
when he championed the drafting of the American Medical Association's
opinion document on medical errors that underscores the central role of
individual physicians in identifying and reducing medical errors. The AMA's
opinion is the focus of our cover story in this issue, "Medical errors and
patient safety: Who's responsible?"
Dear Colleagues, I would like to take a brief moment to review the activities of our district medical society. We continue to be active in the press, writing several letters to the editor and op ed pieces on issues of public and professional consequence such as the compensation of medical injuries, liability reform, tobacco cessation in the workplace, `clean syringes and needles', etc. Our television series `Health Matters', continues to be a great resource to the community and an occasion for our member physicians to share their expertise with taped segments currently being aired in Worcester, Shrewsbury and Hopkinton. Several important resolutions of far-reaching public health and professional consequence, proposed by WDMS, were unanimously approved by the entire house of delegates at MMS, covering issues such as public access defibrillation and the creation of a `heartsafe community', indication of labeling and appropriate use in `direct-to-consumer' advertising by pharmaceutical companies, revision of the formulary program at the Division of Medical Assistance that has led to inordinate amounts of paperwork in the form of PA requests for medication, better control of content of cable television programs in hospitals to decrease violent and other unacceptable content, promotion of a repeal of unfunded mandates such as the requirement for interpreters at patient consultations, at cost to physician or facility, among others. As the cost of practicing medicine increases and reimbursement declines, economic pressures mount and we are all under extreme constraints to perform more in the shrinking workday. In such circumstances, errors are inevitable and hence this issue of Worcester Medicine is so much more relevant, with its focus on patient safety. At the MMS level, patient safety continues to be a focus with educational forums addressing this issue in the coming weeks. Further, the MMS observed Patient Safety Week (March 7-13) through a variety of communications with our members and health care leaders throughout the state. The theme for this year was `The Power of Partnership'. It is exciting to be part of such a dynamic organization and I look forward to your feedback to make the WDMS more meaningful to all of us. Sincerely, George Abraham, MD, MPH
" There is a growing conviction that in all hospitals, even in those that are the best conducted, there is a great and unnecessary waste of life" -- Florence Nightingale, 1858 You are covering for your team over the weekend and you get called with a PT/INR of 7. First, you ask, "What happened? Why did this happen?" and finally, "Who's to blame?" But these are the wrong questions. If we are to make progress in reducing medical errors, we physicians must also ask ourselves, "How can I make sure this doesn't happen again?" Just how serious is the problem of medical errors? Consider these statistics from "To Err is Human: Building a Safer Health Care System," published in 1999 by the Institute of Medicine. According to the report, medical errors are the eighth-leading cause of death in the U.S. Further, medical errors:
Imagine if other industries and professions accepted a 2% error rate. Renowned industrial quality control expert W.E. Deming had this to say about errors, "If we had to live with a 1% failure rate, we would have two unsafe landings per day at O'Hare, 16,000 pieces of mail lost every hour, and 32,000 bank checks deducted from the wrong bank account every hour." Clearly, medicine has a problem. From the results of the patient safety survey reported on pages 10 and 11 in this issue, it is obvious that we physicians are very aware and quite concerned about errors and safety. According to the survey, 80% of us have identified errors in patient care in the past year, but half of us don't know where to go to report these safety concerns. Further, more than half of us have not implemented or worked on systems for reporting and analyzing health care errors. Maybe the culture of medicine prevents us from reporting -- or even admitting to -- an error. According to Edward J. Dunn, M.D., of the VA National Center for Patient Safety, there is an expectation of infallibility. After all, how can there be an error without negligence? The need for infallibility creates undue pressure to cover mistakes, and too often there is a "blame and shame" reaction to poor outcomes. No one goes to work intending to make a mistake. Healthcare today is a complex process, involving many practitioners, organizational issues, training issues, communication problems, new technologies and financial constraints. We are using systems of care that are over half a century old and are in need of revitalization. Yet other industries with equally complex processes are succeeding in reducing error rates. Consider this: in aviation, the risk of death is one in 2 million; in an acute care hospital, the risk of death is one in 200. How is the aviation industry succeeding in safety issues, and where is medicine failing? The Aviation Safety Reporting System (ASRS), founded by Charles Billing in 1975, is based on this important principle: each person has a responsibility, but they each own all of the organization. According to Dr. Dunn, some of the lessons learned from the ASRS can also apply to medicine:
Don Berwick, M.D. CEO of the Institute for Health Care Improvement (IHI), echoes this last point, "You don't get to safe systems that have human beings in them by yelling at them or asking them to work harder. You need to engineer the work environment so that normal human limits are respected." So what do we do? The key to improving patient safety and reducing errors is creating a culture where reporting is not punitive, but encouraged. Large organizations can attempt to institute change, but only if there is a "buy-in" at the local level. Paul O'Neil, former U.S. Treasury Secretary and CEO of Alcoa, noted that the organizing principle of a health system should be the individual patient. . . "You start with the patient and work back." It's clear from the survey that we all know we have a problem, but we don't know where to go or what to do about it. And we often don't have enough time. A typical day in the office for many of us includes: four calls holding, patients waiting in the exam rooms, 15 pre-authorization forms to fill out, labs to review, prescriptions to fill out, calls to the families of your hospitalized patients, and three of your support staff have called in sick. It's no wonder that the task of error reduction and patient safety may not be your top priority. But it needs to be. How do we solve this? Dr. Dunn suggests these principles for improving our systems:
Improvement won't happen overnight -- it must start with small cycles of change. We must take small steps, experiment with change, measure the results and try again. Ask yourself, was that the result you wanted? Did it make a difference? Effective changes don't always start at the systems level -- they can happen right in your own office. Little cycles of change can build on each other to initiate greater change. Start by tackling one or two problem areas, such as anticoagulation management or prescription call-in. Look at the process, decide what can be improved, and make a change -- even if it is a small one -- and measure the result. With the medical mix we have in Worcester -- community physicians and large healthcare systems, St. Vincent Hospital, UMass Memorial and Fallon Clinic -- the important question is, how can we all collaborate to provide a safer environment for our patients? What programs can we share, what forums can we use to discuss ideas, how can we benefit from each other's successes and learn from each other's failures? We all are responsible for improving patient safety and reducing errors. People who make mistakes aren't bad, and working harder isn't the solution. Consider the many processes in place in your office and organization -- which ones don't make sense anymore? Which ones have been in place for so many years that you "just do them" without thinking? According to Dr. Berwick in a recent Boston Globe Magazine, "the fundamentals of the (healthcare) system are so screwed up that it is no longer possible for the medical profession to provide reliable, high-quality care, no matter how many innovations its renowned doctors roll out, no matter how many awards they rack up." One thing is clear, if we remain in a systole about patient safety and medical errors, the prognosis is not good. Berwick's solution is simple, but drastic: "To save the healthcare system, it needs to be blown up." Who's going to light the first match? (Many thanks to Edward J. Dunn, MD, MPH, Director, Policy and Clinical Affairs, VA National Center for Patient Safety, for his advice and expertise in this area). Peter Lindblad, M.D. is a practicing clinician and founding partner of Primary Physician Partners, P.C., Worcester Medical Center, 508-363-7300; E-mail: peter.lindblad@tenethealth.com
Editor's Note: In June 2003, the AMA's Council on Ethical and Judicial Affairs, Report 2, entitled, "Ethical Responsibility to Study and Prevent Error and Harm in the Provision of Health Care", was adopted by the House of Delegates. The Recommendation of Report 2 is now an Ethical Opinion embodied in the AMA's Code of Medical Ethics. The process was guided by Leonard Morse, MD, immediate past chair of the Council on Ethical and Judicial Affairs. At its 2003 Annual Meeting, the American Medical Association's House of Delegates adopted the recommendations of Council on Ethical and Judicial Affairs (CEJA) Report 2 - A-03, "Ethical Responsibility to Study and Prevent Error and Harm in the Provision of Health Care." The report offers guidelines to physicians regarding their ethical responsibility to prevent errors and to disclose them. In December 2003, at the House of Delegates interim meeting, CEJA issued the recommendations of this report as an opinion. The opinion, which follows, will appear in the next versioof the AMA's PolicyFinder database and the next print edition of the Code of Medical Ethics. Opinion E-8.121 Ethical Responsibility to Study and
Prevent Error and Harm (1) Because they are uniquely positioned to have a comprehensive view of the care patients receive, physicians must strive to ensure patient safety and should play a central role in identifying, reducing, and preventing health care errors. This responsibility exists even in the absence of a patient-physician relationship. (2) Physicians should participate in the development of reporting mechanisms that emphasize education and systems change, thereby provide a substantive opportunity for all members of the health care team to learn. Specifically, physicians should work with other relevant health care professionals to:
(3) Physicians must offer professional and compassionate concern toward patients who have been harmed, regardless of whether the harm was caused by a health care error. An expression of concern need not be an admission of responsibility. When patient harm has been caused by an error, physicians should offer a general explanation regarding the nature of the error and the measures being taken to prevent similar occurrences in the future. Such communication is fundamental to the trust that underlies the patient-physician relationship, and may help reduce the risk of liability. (4) Physicians have a responsibility to provide for continuity of care to patients who may have been harmed during the course of their health care. If, because of the harm suffered under the care of a physician, a patient loses trust in that physician, the obligation may best be fulfilled by facilitating the transfer of the patient to the care of another physician. (5) Physicians should seek changes to the
current legal system to ensure that all errors in health care can be safely
and securely reported and studied as a learning experience for all
participants in the health care system, without threat of discoverability,
legal liability, or punitive action. (I, II, III, IV, VIII)
Recently published studies seek to show that increased hospital nurse staffing leads to fewer avoidable errors and better patient outcomes. One such study, submitted in 2001 for the Department of Health and Human Services, concluded that higher levels of nurse staffing or staff skill mix are correlated with lower levels of urinary tract infections, pneumonia, UGI bleeding and shock/cardiac arrest, and lower lengths of stay. Given the apparent linkage between nurse staffing levels and patient outcomes, what can practically be done to adjust those levels? California's experience with the nurse staffing ratios law effective this year is too recent to draw definitive conclusions, but it is even now apparent that merely dictating nurse to patient ratios might not be the most appropriate means of ensuring the right level and mix of nurses in hospitals. For example, the California rule permits hospitals to satisfy many of the nurse ratio requirements through the use of LPNs. Recent studies suggest that patient outcomes that are sensitive to nurse staffing are affected by not only the number of licensed nurses providing care, but the proportion of those nurses who are RNs. Hospitals meeting the ratios by hiring LPNs rather than RNs may be satisfying the regulatory mandate, but not taking steps likely to result in better patient outcomes. Likewise, the California law imposes the ratios as minimum standards to be met at all times, not on average. Some allege this continuous compliance requirement results in increased waiting periods in emergency departments and hospital diversions. One hospital has closed its medical-surgical, intensive care and obstetric beds in part because of its inability to hire enough nurses to meet the nurse staffing standards. The problem of finding enough nurses to satisfy minimum staffing ratio may be particularly acute in California, which ranks 49th among the states in RNs per capita (585 RNs/100,000). (Massachusetts is first in the nation, with an RN to population ratio of 1,190 RNs/100,000.) However, increasing numbers of sicker patients requiring more intensive nursing, difficult nurse working environments, an aging nurse workforce and years of declining enrollment in nursing education programs will increase the demand while decreasing the supply of appropriately trained nurses for a considerable period. One study has estimated that there will be a shortfall of 400,000 RNs by 2020. Achieving better patient outcomes through California-style nurse staffing ratios may become increasingly difficult to implement over time, given the nurse shortage. Other states have taken slightly different approaches. Oregon enacted legislation that requires hospitals to use acuity-based nurse staffing plans. In Texas, proposed rules require the use of nurse-sensitive patient outcomes to adjust nurse-staffing plans. Some other states have considered legislation that would among other things require nurse staffing studies or publication of actual nurse staffing ratios. Massachusetts legislators have proposed many of these approaches over the past year. One Senate bill introduced in 2003 calls for a special task force to study health care workforce issues, including the recruitment and retention of nurses. Another Senate bill sets RN staffing ratios for each licensed health care facility and provides additional Medicaid reimbursement to those facilities scoring well on a scale comprised of the staffing ratios and an evaluation of patient outcomes. Another Senate bill would establish minimum nurse staffing ratios for long term care facilities and impose civil monetary penalties on non-compliant facilities. A bill introduced in the House would do the create staffing ratios, impose limits on mandatory nurse overtime and work assignments, require health care facilities to post the required and actual nurse staffing levels at that facility, and seek to alleviate the nursing shortage, by instituting a nurse recruitment grant program, encouraging employees to obtain the education required to become an RN and helping facilities loan nurses to act as nursing school faculty. Rather than mandating nurse staffing levels, perhaps another way to address quality of care problems associated with nurse staffing is to reform the conditions of nurses' work in hospitals, by reducing paperwork, improving communications with physicians and administrators, providing improved training and technology and changing the patterns of care delivery that increase nurses' sense of authority and control in the workplace. By improving the nurses' work environment, more nurses may be retained, more new nurses might be trained and patient outcomes may be improved. However these issues are played out, it is certain that nurse staffing, and its relationship with medical errors and patient outcomes, will continue to be hotly debated. Peter Martin is an attorney with Bowditch & Dewey, Worcester.
In March 1774, tensions in Worcester between Royalists and Patriots reflected America's revolutionary sentiments. The annual Town Meeting in March laid bare the bitter divisions in the community. A second Town Meeting was called in June, and after angry debate, the Whigs again prevailed. Clark Chandler, the town clerk, copied a harshly worded paper by the Tories into the record -- it certainly was not read at the assembly, for it would have had violent repercussions. It is recorded that Worcester citizens first learned of the remonstration when it was reprinted in the Boston press. 52 Tories, including the well-liked Timothy Paine and his son, Dr. William Paine, had signed what is now known as the Worcester Protest. Another town meeting was called, where it was voted that Town Clerk Chandler "do, in the presence of the town, obliterate, erase, or otherwise deface the said recorded protest, and the names thereto subscribed, so that it may become utterly illegible and unintelligible." Poor Chandler tried to scratch through the offending screed with his quill pen. That, however, being deemed inadequate, the Patriots dipped his fingers in ink and smeared the pages. William Paine was born in Worcester in 1750. His parents, Timothy Paine and Sarah Chandler Paine, were both descended from prominent, wealthy colonial families. "Billie" Paine appears to have had an uneventful childhood, with little being recorded except that he was taught Latin by John Adams, while the future president was reading law locally. Paine is listed second on the list of graduates from Harvard College in 1768 --at that time names were listed in order of "the dignity of the family." The first medical school in America started its first full course of lectures that year. But not surprisingly, Paine chose a traditional apprenticeship with a distinguished physician, Dr. Edward A. Holyoke, in Salem rather than travel to distant Philadelphia to attend an untested school. While there, he met Sarah Orne, who became his wife. The engraved silver Paine ordered from Paul Revere for Sarah, Revere's largest single commission, is on display in the Worcester Art Museum. In 1771, Paine returned to Worcester, presumably expecting to become a leader in the medical profession. He formed a partnership with Levi Shephard, apothecary, and Ebenezer Hunt, Jr., physician of Northampton, as "Traders in the Art, Mystery & Business [of ] an apothecary, and of the Practice of Physick." Shephard and Hunt were to practice as apothecaries and Paine as physician. Neither his medical practice nor his apothecary business was presumably very profitable because of the high political tensions and the coming war. Paine was a committed Tory, and as John Nelson writes in Worcester County. A Narrative History, "Again, and yet again, they [the Tories] were compelled to humiliate themselves publicly in the village Main Street, not only before their fellow towns-people, but before the assembled forces of the county." In August 1774, when smallpox was prevalent, the doctor reapplied, after previous attempts, to establish "a Hospital for Inoculation in said Town and it was Passed in the Negative." Doubtless feeling rejected by his hometown, Dr. Paine sailed for England on September 1. Paine's travels are difficult to track during the next few years. According to the Massachusetts Spy, May 3, 1775, "Messrs. Chandler and Paine of this town [Worcester] are arrived at Salem from London." Apparently, he prudently did not return home then -- "finding the country in most excited state and himself denounced." The Battles of Lexington and Concord had just been fought, and Paine's fervent loyalty to England would have been quite unwelcome in Worcester. In 1779, the Provincial Congress resolved to put Shephard in possession of the apothecary business. It is unclear whether this was an act of confiscation, the result of a lawsuit or another arrangement. While in Britain, in October 1775, Paine was appointed Apothecary of the Hospital for the Forces in North America. In November, he received an M.D. from Marischal College in Aberdeen. This degree has been the subject of discussion because of the short time involved in receiving it; however, the diploma is among his papers at the American Antiquarian Society. Upon his military appointment, he was stationed in Rhode Island and New York and, during that time, recorded a number of case histories. "The Case of McLoud belonging to the Second Battalion of his Majesty's Second Regiment" begins, "This poor young Creature after repeated retourns [sic] of Hernia and some slight venereal complaints became a Victim to Death thro' carelessness and bad practice like many more unfortunate men under the same persons hand." Paine recounts the bleeding, mercurial pills and course of care for five days. Another soldier "in His Majesty's Service at Skenectady [sic] was wounded by a sharp pointed instrument" in the knee, which resulted in a "violent inflammation." After 14 days of treatment, the physicians and surgeons "propose [d] the operation to the patient for his relief, which accordingly happened. He objected strongly to it for some hours, nay all that day, but repeated solicitations prevailed over him to consent to be dismembered the following day." In January 1781, Paine traveled as personal physician to Lord Winchelsea. He kept a daily log of the stormy winter Atlantic crossing. Sea sickness, a "cabin so wet that my Boots are very mouldy [sic] every morning and the bed cloths wet," snow, and hail made the trip a "hazardous Expedition.... Never were poor Devils in a worse Situation, we are absolutely lost -- The Captain and his Mate differ in their reckonings ten degrees of Longitude." They missed a supply stop at Madeira and were blown to Lisbon instead of landing as planned in England. Once in London, Paine passed a three-part examination over a period of three months to be elected Licentiate of the Royal College of Physicians. A year later, in October 1782, he was commissioned "Physician to His Majesty's Hospitals within the District of North America," the equivalent of Surgeon General. Stationed in Halifax, Nova Scotia, where many Royalists from New England had settled, he fulfilled his duties "active in the management of hospitals, in the purchasing of stores and, to a lesser degree, in the care of sick and wounded soldiers." About the end of October 1783, British troops were withdrawn and his duties ended. He was placed on half pay, retained his rank and received a land grant from the English for his service in the war. During the 1780s, Paine was spending more and more time in Salem. He joined the Massachusetts Medical Society in 1790 and was elected to the American Academy of Arts and Sciences. In 1793, when his father died, he returned to Worcester to the family residence, The Oaks. At the start of the War of 1812, Paine was still a half-pay officer in the British forces and ordered to report for service. Tradition tells us he then resigned his commission and chose to stand with his countrymen. In June 1812, he petitioned the Legislature to become a naturalized citizen of the United States, and it was resolved that this would occur "whenever William Paine shall bring himself within the provisions of the several statutes of the United States which establish a uniform rule of naturalization, and shall make due application to any Court of Record to be admitted as a citizen of the same..." No court record or other document has been found to verify that he did this. Paine's Worcester journals record in detail the chores of the seasons -- picking apples, chopping wood, planting potatoes, etc. He rarely mentions medicine. Paul Bergin, in A History of the Worcester District Medical Society, 1794-1954, writes, "he [Paine] lived forty years in his ancestral home on Lincoln Street, practicing medicine to some extent but distinguished rather as a man of Letters than as a physician." It seems fitting that The Oaks, home to William Paine the Royalist, later William Paine the American, should now be the home of the Timothy Bigelow Chapter of the Daughter of the American Revolution. During the Revolution, many Worcester families, friends and neighbors were divided by their loyalties. Probably few were more intertwined in partisan hostilities than Dr. "Billie" Paine. Sande Bishop is a local historian specializing in the development of medicine in Worcester.
January 29, 2004 Dear Paul, On behalf of the Massachusetts Medical Society's Arts, History, Humanism & Culture Member Interest Network, we would like to thank you and Worcester Medicine for once again dedicating a special issue featuring the 2003 MMS Creative Writing contest. The issue was very well done and received many compliments by the writers and other recipients. It is a wonderful way to showcase the talents of our medical colleagues. We look forward to continuing with a 5th annual contest for 2004. The magazine will be distributed at the MMS Annual Meeting in May so will reach a wide range of members to whom we will showcase your district's unique magazine. Best Regards,
Abraham Everett Rosen, MD Dr. Abraham Everett Rosen, who practiced general medicine in Worcester for over 40 years, died on May 15, 2003 at the age of 93. He was born in Bangor, Maine, graduated from Tufts University School of Medicine and completed his post-graduate training at St. Vincent Hospital in Worcester. While serving as a Lt. Colonel in the U.S. Army Medical Corps. during World War II, he was injured in an invasion of the Island of Mindanao. Dr. Rosen was beloved by his patients. His demeanor was soft and gentle, perhaps due, in part, to a hearing loss. Always polite and never hurried, he commonly made his hospital rounds at night taking advantage of a quieter setting as well as having access to laboratory data on the day it was reported. Dr. Rosen's unblemished career ended in 1987 when he relinquished his license after allegations of improper prescribing resulting from a series of sting operations. Despite the sad conclusion of his practice, he rose above it, knowing that he had been devoted to his patients and, that judgment, not avarice, governed his prescribing decisions. As a nonagenarian, Dr. Rosen's experiences were vast. He typified William Osler's aphorism, that "the young doctor knows all the rules, while the old doctor knows the exceptions to the rules!" It should also be known that Dr. Rosen never sent a bill to a patient! Ruth, Dr. Rosen's wife of 60 years, predeceased him. They did not have children. By Leonard J. Morse, MD |