Who Can I Trust? Ensuring Physician Competence

Gwyneth Vives, a scientist at Los Alamos National Laboratory in New Mexico, suffered a complication and bled to death 3 hours after giving birth to a healthy boy in 2001. It was 4 days before Christmas. Vives suffered a vaginal tear and other lacerations during the delivery that caused profuse bleeding. Her obstetrician, Pamela Johnson, was sued for failure to order a blood transfusion for Vives as well as abandonment since she had turned over repair of the vaginal tear to a midwife. Two other patients also sued Johnson. Jean Challacombe alleged that Johnson tore her bowel and uterus while doing a dilation and curettage the same day Vives died. Tanya Lewis accused Johnson of doing an unnecessary hysterectomy.

The Government Responds: The Agency for Healthcare Research and Quality

When the IOM report started the patient safety movement by converting the safety interest of a few into the concern of the many, those who wished to enter this emerging field had little to work with: few measures, few proven safe practices, and few standards. For the patient safety movement to blossom in the ways envisioned by the IOM, a substantial amount of foundational work would be necessary. Only the government could provide the resources that were needed to accomplish this work.

Setting Standards: The National Quality Forum

When AHRQ assumed the responsibility from the Quality Interagency Coordination Task Force (QuIC) report, Doing What Counts for Patient Safety, to develop practice changes to reduce harm from medical errors, it faced two problems: there were few proven safe practices, and there was a dearth of standards by which to evaluate them. A standard setter was needed.

Partners in Progress: Patient Safety in the UK

In 1997, Britons were shocked by a report from the General Medical Council (GMC) of a series of deaths from bungled surgery at the Bristol Royal Infirmary. In response to parents’ complaints, the GMC had launched an investigation into the high mortality of cardiac surgery of children at the Infirmary. It found that of 53 children who were operated on, 29 had died and 4 suffered severe brain damage. Three surgeons were found guilty of serious professional misconduct, and two were stricken from the medical register [1].

Correction to: Everyone Counts: Building a Culture of Respect

Chapter 21 in: L. L. Leape, Making Healthcare Safe

A Community of Concern: The Massachusetts Coalition for the Prevention of Medical Errors

One day in January 1997, John Noble, an internist from Boston City Hospital who I knew from somewhere—perhaps residency days—walked into my office and said, “We should form a state coalition for the prevention of medical errors.” His idea was to bring to the table the key players in health who tended not to talk much with one another—regulators and the regulated, academics and practitioners, etc.

Now the Hard Part: Creating a

In 2020, the coronavirus pandemic killed 1,800,000 people, 346,000 of them Americans. In that same year, if recent estimates are correct, about the same number died as a result of medical errors, all despite the enormous effort of the past 20 years to eliminate preventable harm, an effort that has involved people at all levels: policy makers, government agencies, oversight bodies, quality improvement organizations, major health-care systems, and thousands of providers and caregivers on the frontline.

Make No Little Plans: The Lucian Leape Institute

Despite encouraging progress in the early years of the patient safety movement, it soon became evident that there were deeper issues that needed to be addressed. We realized that we were not going to make health care safe by making process changes one by one, even powerful changes such as eliminating CLABSI or implementing the surgical checklist.

Enforcing : The Joint

On March 30, 1981, Ronald Reagan, president of the USA, was shot in an assassination attempt. During his lifesaving surgery at the George Washington Hospital, the nation was riveted by the clear and calm account of its progress by the hospital’s physician spokesman, Dennis O’Leary. Five years later, O’Leary became the head of the Joint Commission on Accreditation of Hospitals.

Spreading the Word: The Salzburg Seminar

Salzburg! The name conjures up images of the annual world-famous Salzburg Festival and The Sound of Music, with its magnificent castle and the glorious singing of Julie Andrews. The birthplace of the divine Mozart.