Stop medical errors with accountability, not shame
August 11, 2012 by admin
Filed under Choosing Lingerie
Like so many other mothers across the country, my heart breaks for the parents of Rory Staunton, the 12-year-old who died tragically in April after a series of apparent medical errors and misdiagnoses at NYU Langone Medical Center.
Medical errors in a different New York hospital threatened the life of my son, Henry, when he was just 3 weeks old. After hours of anguish, we were lucky: Henry survived a routine surgery even after botched care. That error almost deprived the world of my funny, compassionate, smart boy, today a strapping 6-foot tall teenager. But every year more than 200,000 people aren’t so lucky, killed by preventable medical mistakes and infections in American hospitals.
Here’s what is particularly frightening to those of us who know about hospital accidents: The needless errors that caused Rory’s death happened in one of the nation’s most outstanding hospitals. According to publicly available data on patient safety, NYU Langone isn’t flawless, but it is among the safest hospitals in the country.
I have no financial interest in NYU and don’t know anyone who works there, but I do have sympathy for the men and women, the vast majority of them outstanding professionals, who must live with the mistakes that took Rory’s life. And I am certain that we won’t prevent another tragedy like this merely by pointing fingers and making doctors and nurses feel more terrible than they already do. Mistakes happen. The key question is whether hospitals manage the inevitability of human error by creating organizational safety nets that prevent any one mistake from causing catastrophe to the patient.
The biggest issue is culture. In other industries known for safety, like highly productive manufacturing plants, all workers are empowered to speak up when they observe a potential hazard, and managers that disparage such conduct are dispatched from service.
In Rory’s case there were other errors such as medical chart errors, communication problems, a false or delayed lab or radiology report or something else. Much can go wrong in a complex environment like a hospital. Safety nets are essential.
Hospitals must also lose their defensiveness — rather than closely guarding safety data that should be available to the public for scrutiny. After a decade of advocacy by my organization and many others, we now have some information about hospital safety publicly available from the federal government and states. Much more is needed.
But it’s not just health care institutions themselves that have work to do. Critics need to move beyond the understandable urge to angrily assign blame — and work in good faith to improve care. Patients have a part to play, too. If more New Yorkers made clear to their doctors and nurses that they are choosing hospitals on the basis of their safety record, safety would quickly rise to the top of the priority list for every hospital.
New York City has some of the best restaurants, theaters and shopping in the world in part because New Yorkers are not shy. New Yorkers need to lose their shyness about getting tough on their hospitals.
Based on the data we have, I would still entrust the care of anyone in my family to NYU Langone Medical Center, because they are safer than so many other hospitals. It has earned a measure of trust and even love from the community it serves. But as Rory’s tragedy reminds us, let’s make sure it’s tough love.
Binder is president and CEO of The Leapfrog Group, an independent national nonprofit that recently released the Hospital Safety Score — letter grades reflecting how safe hospitals are for patients, modeled after the restaurant safety grades in New York City.
