Citations to IOM report


2002 Citations to the Institute of Medicine Report These are "leads" only - Contact publishers for full text.	http://md-jd.info http://md-jd.info/errors.htm

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Other Years - Leads: 1999.2000.2001.2002.2003

The Advocate (Baton Rouge, LA.)
December 27, 2002, Friday METRO EDITION
Study finds medical errors caused by multiple factors not just bad doctors and their mistakes
    The public thinks medical errors occur because of bad doctors, but it's not that simple, according to a national expert on patient safety and medical errors.
   Dr. Donald Goldmann, an investigator at the Harvard Center of Excellence for Patient Safety Research, spoke on "Reducing Medical Errors: Creating a Safe Work and Care Environment" at a recent LSU Health Sciences Center health forum here.
   Between 44,000 and 98,000 people die in the United States every year as a result of medical errors, according to two studies cited by the Institute of Medicine in its report "To Err is Human: Building a Safer Health System." Even the lower estimate makes medical errors the eighth leading cause of deaths in the country, higher than motor vehicle accidents, breast cancer and AIDS.

The New York Times
December 18, 2002, Wednesday, Late Edition - Final
Errors That Kill Medical Patients
Medical errors are killing tens of thousands of Americans each year and harming countless more, so it has been a salutary trend that many medical, academic and business groups have been developing ways to reduce the dangers. But now a survey of practicing physicians has revealed disheartening evidence that the doctors themselves may be the biggest obstacle to effective reform.
Three years ago the Institute of Medicine estimated that 44,000 to 98,000 patients die each year because of medical mistakes -- more than are killed annually by automobile accidents. The numbers seemed so staggering that many medical practitioners thought them inflated. But the survey of physicians, published in The New England Journal of Medicine last week, has offered corroborating evidence that, whatever the number of deaths might be, there are an awful lot of medical mistakes causing an awful lot of damage.

Health & Medicine Week
DATE1: December 16, 2002
December 16, 2002
INFORMATION TECHNOLOGY: IT may help solve healthcare crisis, experts say
    Mounting evidence suggests that the use of information technology in healthcare can substantially reduce medical errors and translate into major cost savings.
   Recently, prominent healthcare leaders across the public and private sectors said that despite this fact, the U.S. healthcare system has not yet moved its information technology capability into the 21st century. They called for swift change to address the country's looming healthcare crisis brought about by rising costs, changing demographics, and concerns about healthcare quality and safety.
   The call for "healthcare connectivity" came at the third annual Health Legacy Partnership (HELP) Conference and eHealth Initiative annual meeting, cosponsored by a public-private partnership consisting of the Joseph H. Kanter Family Foundation, the eHealth Initiative, the Office of Public Health and Science of the Department of Health and Human Services, the Agency for Healthcare Research and Quality (AHRQ), and the Centers for Disease Control and Prevention.

Telegram & Gazette (Massachusetts)
December 16, 2002 Monday, ALL EDITIONS
Patient safety; Preventing medical errors deserves priority
A new survey of physicians and patients indicates medical errors continue to warrant serious concern.
The poll, conducted by the Kaiser Family Foundation and Harvard School of Public Health, suggests that 42 percent of Americans have experienced a medical error in their care or that of family members.

The Record (Bergen County, NJ)
December 13, 2002 Friday All Editions
Medical errors affect many, outrage few; Study findings surprise researchers
    Medical errors have personally affected many doctors and members of the general public, yet neither group thinks the mistakes are a major health care problem, according to a new survey.
   The study, conducted by the Harvard School of Public Health and the Kaiser Family Foundation, comes two years after a landmark report suggested that 44,000 to 98,000 Americans are killed by medical errors each year, and after follow-up reports and efforts to reform medical practices.
   "We were more than a little bit surprised at the attitudes we found, and particularly how both doctors and the general public felt about possible solutions," said Drew Altman, president of the foundation.

Harvard Crimson via U-Wire University Wire
December 13, 2002, Friday
Study finds medical errors oft perceived
More than one-third of U.S. doctors and nearly half of the public say they or members of their family have been victims of medical errors, a study published yesterday by the Harvard School of Public Health and Kaiser Family Foundation found. Of the 831 physicians and 1,207 adults examined in the April-July nationwide survey, 7 percent of physicians and 10 percent of the public reported these errors had resulted in death, while 6 percent and 11 percent, respectively, said they caused long-term disability.
"It's an epidemic," said Andrew Meyer of Lubin & Meyer, a Boston law firm that specializes in medical cases.

American Health Line December 12, 2002 Thursday MEDICAL ERRORS: DOCTORS, PUBLIC DISAGREE ON CAUSES, SOLUTIONS,; SURVEY FINDS
While 35% of doctors and 42% of patients say they or a family member have experienced a preventable medical error, physicians and the public disagree on the causes of medical errors and what should be done when such mistakes occur, according to a new survey, the Washington Post reports. Appearing in the Dec. 12 issue of the New England Journal of Medicine, the survey includes responses from 831 doctors and 1,207 adults and represents the first attempt to measure the public's experience with medical errors and their opinions on how to prevent them, the Post reports. The survey, designed and analyzed by researchers with the Kaiser Family Foundation and the Harvard School of Public Health, comes after the Institute of Medicine three years ago released a report that estimated between 44,000 and 98,000 Americans die as a result of preventable medical errors. According to the survey, 7% of physicians and 10% of the public say someone in their family has died as a result of a preventable medical error, and 12% of doctors and 17% of the public reported that they or a relative experienced a serious medical mistake that caused them to miss school or work. Kaiser Family Foundation President Drew Altman said the survey's findings serve as "significant corroborating evidence" for the IOM report. The survey indicates a high rate of "perceived substandard care" among respondents, but when asked to name the top problems facing the medical field, respondents did not list medical errors (Brown, Washington Post, 12/12).

The Atlanta Journal and Constitution
December 12, 2002 Thursday Home Edition
Public, docs differ on errors
    Hospitals should be required to disclose medical errors, most people believe, but doctors oppose mandatory reporting, preferring better error-tracking systems and the hiring of more nurses to reduce errors.
   The differing views, revealed in a study in today's New England Journal of Medicine, illustrate the challenges of curbing medical mistakes, which cause up to 98,000 deaths each year in hospitals, according to the government.
   "This is not going to be an easy problem to address," said Drew Altman, president of the Kaiser Family Foundation, which did the study with the Harvard School of Public Health by surveying doctors and the public.

Deseret News (Salt Lake City, Utah)
December 12, 2002, Thursday
SECTION: WIRE; Pg. A09
Medical errors played down
    Medical errors have personally affected many doctors and members of the general public, yet neither group thinks the mistakes are a major health-care problem, according to a new survey.
   The study, conducted by the Harvard School of Public Health and the Kaiser Family Foundation, comes two years after a landmark report suggested that 44,000 to 98,000 Americans are killed by medical errors each year, and after follow-up reports and efforts to reform medical practices.
   "We were more than a little bit surprised at the attitudes we found, and particularly how both doctors and the general public felt about possible solutions," said Drew Altman, president of the foundation.

The Washington Post
December 12, 2002, Thursday, Final Edition
Checking Up on Medical Mistakes; Study Finds Doctors, Members of Public Diverge on Causes
About 7 percent of physicians and 10 percent of the general public say that someone in their family has died as the result of preventable errors in their medical care, according to a new survey.
A higher fraction of each group -- 12 percent of doctors and 17 percent of the public -- reported that they or a relative had suffered a medical error serious enough to cause them to lose time from school or work.
In all, 35 percent of physicians and 42 percent of the public said they had experienced a medical error themselves, or had one affect a family member. Eighteen percent of physicians and 24 percent of the public said the errors had serious consequences.

Cox News Service
December 11, 2002 Wednesday
Public, doctors differ over solution to errors
    Hospitals should be required to disclose medical errors, most people believe, but doctors oppose mandatory reporting, preferring better error-tracking systems and the hiring of more nurses to reduce errors.
   The differing views, revealed in a study in today's New England Journal of Medicine, illustrate the challenges of curbing medical mistakes, which cause up to 98,000 deaths each year in hospitals, according to the government.
   "This is not going to be an easy problem to address," said Drew Altman, president of the Kaiser Family Foundation, which did the study with the Harvard School of Public Health by surveying doctors and the public.

The Washington Post
December 09, 2002, Monday, Final Edition
A Medical Enron
ENRON AND its successor scandals have shown that one should be skeptical of highly qualified professionals -- in those cases, accountants -- who promise to regulate themselves. This skepticism should now be applied to doctors. As The Post's Sandra G. Boodman reported last week, the medical profession is making scandalously slow progress in reducing the rate of medical errors in hospitals -- errors that, according to an Institute of Medicine study three years ago, kill between 44,000 and 98,000 patients annually while injuring perhaps 1 million more.

Health Care Strategic Management
December 1, 2002
Health care sector has yet to embrace the benefits of IT in reducing errors, lowering costs; Database Notes.
     The U.S. health care system has not yet moved its information technology capability into the 21st century despite evidence that its use can substantially reduce medical errors and translate into major cost savings, according to speakers at a recent e-Health forum.
    Speakers at the Third Annual Health Legacy Partnership (HELP) Conference and e-Health Initiative Annual Meeting noted that the health sector lags significantly behind the financial and retail sectors in using existing information technology, despite the improvements in cost-effectiveness and quality that could be made through its use. Industry leaders are calling for the swift implementation of an interoperable electronic infrastructure connecting different systems within health care, including electronic health records, which according to recent estimates could save up to $ 80 billion per year.
    "This is the Information Age, the beginning of the 21st century, and yet we have not addressed the problem of standardizing the collection and sharing of health data electronically, so that patients and clinicians will have the information to determine which treatments work best for specific conditions. The technology to standardize software and systems so they can communicate with each other already exists," said Joseph H. Kanter, chairman of the Joseph H. Kanter Family Foundation.

PR Newswire
November 26, 2002, Tuesday
First DataBank Introduces Medication Dosage Checking for Neonates
Content Helps Prevent Medication Errors in Newborns and Infants
SAN BRUNO, Calif., Nov. 26 /PRNewswire/ -- First DataBank today announced the release of a new clinical knowledge base that screens medications for newborns and infants, to detect dosing errors. Medication errors in general can lead to longer hospital stays, increased costs, and even death. The new content, the Neonatal and Infant Dosage Range Check Module(TM), is specialized for this unique population of young, sensitive patients, while complementing similar First DataBank modules for adults. According to Virginia Halsey, Senior Product Manager, the new module is designed to prevent dosing errors in neonates and infants by factoring in two critical patient characteristics -- weight and gestational age at birth. The importance of this new information, Halsey said, can be measured by the response both of hospitals and of information system vendors. "Key vendors are already incorporating this data into their products because of the pent-up demand from the healthcare community." The new First DataBank module is currently shipping, and covers the drugs most commonly used for these patients in an acute-care setting. For some time now, Halsey explained, healthcare providers have been urgently seeking a solution to the problem of dosing errors in newborns. As one recent large-scale study of medication errors in children concluded, "...pediatric patients may be more vulnerable to adverse outcomes from medication errors than adult patients."(1) Many healthcare information system suppliers, after anxiously awaiting a database on neonatal dosing ranges, have put these products on a fast track, to take advantage of this opportunity.

ManagedHealthcare.Info
DATE1: November 18, 2002
November 18, 2002
MEDICAL RECORDS: Experts call for reform in electronic medical record keeping
    Medical, academic and government experts say the $1.3 trillion healthcare industry is wasting money and endangering patients because of its inability to connect patient records among providers and collect data on best practices.
   Medical errors account for between 44,000 and 98,000 deaths each year in hospitals, costing up to $50 billion, partly because of a fragmented system of record keeping, they said.
   Between 10% and 81% of the time, doctors do not have access to patient information that has already been recorded in a paper-based filing system, according to data presented at the third annual conference of the Health Legacy Partnership and eHealth Initiative. The eHealth Initiative is an organization of private and nonprofit health organizations dedicated to using information technology to improve quality, safety and cost-effectiveness of health care.

The Stuart News/Port St. Lucie News (Stuart, FL)
November 16, 2002, Saturday
HIGH-POWERED HYPOCRITES LIVE IN MEDICAL-LEGAL WORLD

In reference to Attorney at Law Maura Sorenson's letter published Nov. 7 [ "Helmet law repeal has cost Floridians lives and money"], and in rebuttal to what the legal, insurance and medical communities say:
For years we've heard these groups claim that motorcyclists riding without helmets are a huge public burden to taxpayers because of medical costs. In an article in USA Today headlined "Medical Mistakes 8th Top Killer," the Nov. 30, 1999 article claims that medical errors kill more people in the United States than traffic accidents, breast cancer or AIDS.

AORN Journal
November 1, 2002
First, do no harm; President's Message; Editorial
     This month marks Perioperative Nurse Week, Nov 10-16. This year the theme is "Your safety is our job ... We take it seriously!" The intent of Perioperative Nurse Week is not for nurses to celebrate nursing, although nursing can and should be celebrated. The overall goal of Perioperative Nurse Week is to inform the public about nurses' roles in their care when they undergo surgical interventions. More than ever, it is critical for consumers to be aware of our efforts as members of the surgical team and to recognize AORN's activities aimed at ensuring that every patient experiences a safe surgical intervention and outcome when entering the OR.
    BRINGING ERRORS INTO THE LIGHT
    These days, consumers are more acutely aware of the potential for medical error, in part because of the 2000 Institute of Medicine (IOM) report, To Err is Human: Building a Safer Health System. (1) The report estimates that between 44,000 and 98,000 patient deaths occur annually from adverse medical and surgical events. The estimated cost for these errors is between $ 8.5 billion and $ 17 billion annually.

Health Management Technology
November, 2002
Technology's Impact on Reducing Medication Errors
    We all know the statistics by heart -- an estimated 44,000 to 98,000 patients die every year because of needless medical errors in the very places they should be recovering from illness or injury.
   At Danville Regional Health System in Danville, VA, we were just as alarmed by these findings as every healthcare provider in the country. However, long before the Institute of Medicine (IOM) report, "To Err is Human," was released, our staff understood the power of technology to optimize the care provider's daily workflow and to help ensure patients' safety and well-being.
   Danville Regional Medical Center (DRMC), 50 miles north of Greensboro and the centerpiece of the health system, is a 350-bed acute care hospital. Among many services, it offers an outpatient testing center, comprehensive surgical services, a 24-hour emergency department, a cardiac rehabilitation program, a cardiac catheterization lab, complete radiology services, pediatric services, critical care unit and laboratory services.

Canadian Pharmaceutical Journal
November, 2002
Medical errors are preventable
The death of Ryan Lucio in late September is yet another reminder of the human cost of medical errors. Ryan, a four-year-old diagnosed in January with a severe case of neuroblastoma, was given a fatal overdose of an experimental cancer drug. According to officials with the Children's Hospital of Eastern Ontario, the dosage of the drug, Interleukin II, was miscalculated and escaped the notice of 15 professionals involved in the clinical trial.
[Graph Not Transcribed]
Though it's debatable whether an error tracking system could have prevented this tragedy, many believe a national monitoring system, improved legal and regulatory processes, and changes to the culture surrounding error reporting might lessen future mistakes.

The New York Times
October 31, 2002, Thursday, Late Edition - Final
Study Tells U.S. to Pay More For the Best Medical Care
The National Academy of Sciences said today that Medicare, Medicaid and other government programs should reward high-quality health care by paying higher fees or bonuses to the best doctors, hospitals, nursing homes and health maintenance organizations.
In a report requested by Congress, the academy said the federal government should establish standard measures of quality, assess the performance of each health care provider and publish comparative data for use by consumers.

The Washington Post October 31, 2002, Thursday, Final Edition Agencies Urged to Join Forces on Care Quality; Panel Calls for Data on Medical Providers
A half-dozen federal health programs that funnel care to nearly 100 million Americans should combine their leverage to improve the safety and quality of medical treatment, according to a new report, which calls for a major new campaign to collect and publicize information about how well doctors, hospitals and other providers of care do their jobs.
The study, issued yesterday by the Institute of Medicine, concluded that federal programs -- covering poor children to military veterans -- are fragmented in their efforts to improve quality and fail to harness their massive purchasing power to compel better care.
The report recommends that the programs agree on 15 major types of care, then require all health providers with government contracts to submit detailed data about their treatment of patients with those conditions.

Iowa City Press-Citizen
October 29, 2002 Tuesday
Stop malpractice legislation
    U.S. House proposal will remove the incentive and ability to bring medical negligence lawsuits
   On Sept. 26, the Republican-controlled U.S. House of Representatives passed medical malpractice legislation that limits a patient's recovery for medical negligence and limits attorney's fees. Although unlikely to pass the Senate this year, Republican control of the Senate next year increases the chance that this legislation will pass in the next two years.
   The legislation's goal is to remove the incentive and ability to bring medical negligence actions. People harmed by medical negligence will be deprived of justice, and negligent providers will be allowed to continue to practice without having to accept responsibility. Inevitably, we will have to bear the responsibility to care for those injured by the healthcare system.

PR Newswire
October 29, 2002, Tuesday
Nation's Health Care is in 'Critical Condition': Interconnected Electronic Health Information Infrastructure Offers Best Chance for Speedy Recovery; Health Legacy Partnership Convenes Public and Private Sector Leaders to Address Health Care Challenges
Mounting evidence suggests that the use of information technology in health care can substantially reduce medical errors and translate into major cost savings. Today, prominent health care leaders across the public and private sectors said that despite this fact, the U.S. health care system has not yet moved its information technology capability into the 21st century. They called for swift change to address the country's looming health care crisis brought about by rising costs, changing demographics and concerns about health care quality and safety. The call for "health care connectivity" came at the Third Annual Health Legacy Partnership (HELP) Conference and eHealth Initiative Annual Meeting, co-sponsored by a public-private partnership consisting of the Joseph H. Kanter Family Foundation, the eHealth Initiative, the Office of Public Health and Science of the Department of Health and Human Services, the Agency for Healthcare Research and Quality (AHRQ), and the Centers for Disease Control and Prevention (CDC). Reporting on the state of eHealth in the nation, speakers at the conference noted that the health sector lags significantly behind the financial and retail sectors in using existing information technology, despite the improvements in cost-effectiveness and quality that could be made through its use. Industry leaders are calling for the swift implementation of an interoperable electronic infrastructure connecting different systems within health care, including electronic health records, which according to recent estimates could save up to $80 billion per year. Explaining the need for interconnected health care information that will support better patient care and health outcomes, Joseph H. Kanter, chairman of the Joseph H. Kanter Family Foundation, said, "This is the Information Age, the beginning of the 21st century, and yet we have not addressed the problem of standardizing the collection and sharing of health data electronically, so that patients and clinicians will have the information to determine which treatments work best for specific conditions.

Business Insurance
October 21, 2002, Monday
Medical error reporting spurs concerns; Risk managers support goal of improving safety, but wary of potential liabilities under legislation

   CHICAGO-Four patient safety bills now before Congress have significant liability and insurance implications for the nation's hospitals, say risk managers who support efforts to influence the legislation's outcome.
   The bills address the reporting of medical errors by hospitals as a way to improve patient safety. Such legislation could help hospitals cultivate a ' 'culture of safety,'' reduce mistakes and improve their risk profile, say risk managers.
   Or, they say, the bills could discourage the reporting of medical errors and increase potential hospital liability, depending on the legislation's final wording and outcome.

Business Week Online
October 16, 2002 Wednesday
How High Tech Is Operating on Medicine; Doctors and machines that move as one, pacemakers that collect and transmit data, seamless treatment-support systems...
    Needle biopsies are messy medical procedures. Patients risk punctured organs if physicians make even slight mistakes. And tiny malignant growths can elude the aim of even the most skilled surgeon. Worse, biopsies can create significant post-operative pain if doctors have to adjust the trajectory of the needle in mid-test.
   Where a physician might waver, however, a robot could aim true. At least, that's the theory of Daniel Stoianovici, director of Johns Hopkins University's URobotics Lab in Baltimore. Stoianovici and his fellow scientists have built a needle-wielding robot, designed to work in conjunction with magnetic-resonance imaging (MRI) systems, that can achieve accuracy to within one-tenth of a millimeter -- much better than is possible with the human hand.
   To function inside the snug MRI chamber, the robot had to be no larger than a human arm. And because the MRI's strong magnetic field prohibits the use of metal, Stoianovici built his device out of ceramics, plastics, and rubber. Hydraulic pulses sent from a pumping station hooked up to a computer power six small motors that finely position the robot's slender arm and drive the needle into the body.

Marketletter
October 14, 2002
Children in medication error danger; Brief Article; Statistical Data Included
Children who are seen in US hospitals' emergency department between 4 am and 8 am or at weekends, and those with severe diseases, are 1.5-2.5 times more likely to suffer from medication prescribing errors, claims a new study.
Eran Kozer and colleagues at the Hospital for Sick Children in Toronto, Canada, who carried out the study, also noted that errors were more likely when a trainee doctor had ordered the medication.

Pharma Marketletter October 14, 2002 Children in medication error danger
Children who are seen in US hospitals' emergency department between 4 am and 8 am or at weekends, and those with severe diseases, are 1.5-2.5 times more likely to suffer from medication prescribing errors, claims a new study.
Eran Kozer and colleagues at the Hospital for Sick Children in Toronto, Canada, who carried out the study, also noted that errors were more likely when a trainee doctor had ordered the medication.

Fort McMurray Today (Alberta, Canada) September 19, 2002 Thursday Final Edition $50M NEEDED TO ID, REDUCE MEDICAL ERRORS: TASK FORCE
Canada needs to invest $10 million a year over the next five years to create a national institute to identify, track and find ways to reduce medical errors, says a special task force on patient safety.
''The whole idea is not just to measure them and throw up our hands, but rather to find ways to problem-solve and eliminate them,'' said Dr. John Wade, chair of the national steering committee on patient safety, which will announce 19 recommendations next week.

National Journal's CongressDaily
September 19, 2002 Thursday
Correction Appended 10:30 am Eastern Time am SECTION: HEALTH Ways And Means Approves Medical Error Reporting System
The House Ways and Means Committee Wednesday approved a bill aimed at reducing medical errors by setting up confidential, voluntary data banks to receive and study information from hospitals, physicians and others.
The data banks - called Patient Safety Organizations and certified by the Department of Health and Human Services - would analyze reported mistakes and provide feedback on ways to avert future errors.
The identity of those reporting the errors and those committing them would be kept confidential by the PSOs. CORRECTION-DATE: September 20, 2002 CORRECTION: An article in Thursday's CongressDailyAM incorrectly reported that medical error data would not be subject to discovery for civil or criminal proceedings under a House bill. The data would be subject to discovery in criminal matters, but not civil or administrative.

The Brockville Recorder & Times (Ontario, Canada)
September 18, 2002 Wednesday Final Edition
LOOKING FOR WAYS TO REDUCE MEDICAL ERRORS; CANADA MUST INVEST $50 MILLION TO IDENTIFY, ELIMINATE MISTAKES, TASK FORCE SAYS
Canada needs to invest $10 million a year over the next five years to create a national institute to identify, track and find ways to reduce medical errors, says a special task force on patient safety.
"The whole idea is not just to measure them and throw up our hands, but rather to find ways to problem-solve and eliminate them," said Dr. John Wade, chair of the national steering committee on patient safety, which will announce 19 recommendations next week.

The Daily Herald-Tribune (Grande Prairie, Alberta)
September 18, 2002 Wednesday Final Edition
$50M SOUGHT TO BATTLE MEDICAL ERRORS
Canada needs to invest $10 million a year over the next five years to create a national institute to identify, track and find ways to reduce medical errors, says a special task force on patient safety.
''The whole idea is not just to measure them and throw up our hands, but rather to find ways to problem-solve and eliminate them,'' said Dr. John Wade, chairman of the national steering committee on patient safety, which will announce 19 recommendations next week.

Portage Daily Graphic (Manitoba, Canada) September 18, 2002 Wednesday Final Edition CANADA MUST INVEST $50 MILLION TO REDUCE MEDICAL ERRORS: TASK FORCE
Canada needs to invest $10 million a year over the next five years to create a national institute to identify, track and find ways to reduce medical errors, says a special task force on patient safety.
''The whole idea is not just to measure them and throw up our hands, but rather to find ways to problem-solve and eliminate them,'' said Dr. John Wade, chair of the national steering committee on patient safety, which will announce 19 recommendations next week.

Tampa Tribune (Florida)
September 18, 2002, Wednesday, FINAL EDITION
Consumer Group Faults Regulators For Malpractice
    PERPETRATORS NOT MADE TO PAY, IT SAYS
   TAMPA - A consumer group offers this assessment of Florida's ailing medical malpractice situation: State regulators have failed to rein in a small percentage of doctors generating the majority of malpractice claims.
   That was the principle finding of a study issued Tuesday by Public Citizen, a Washington advocacy group that said Florida's medical community has made "sensational allegations" about a malpractice "crisis."
   Florida medical executives denounced the study and pointed to other research that shows the state aggressively disciplines errant doctors and that malpractice rates have skyrocketed because of runaway jury awards.

Toronto Star
September 18, 2002 Wednesday Ontario Edition
Watchdog urged on medical mistakes
Vanessa Lu   Canada needs to invest $10 million a year over the next five years to create a national institute to identify, track and find ways to reduce medical errors, according to a special task force on patient safety.
   "The whole idea is not just to measure them and throw up our hands, but rather to find ways to problem-solve and eliminate them," said Dr. John Wade, chair of the national steering committee on patient safety, which will announce 19 recommendations next week.
   "We are never going to eliminate adverse outcomes, but we need to figure out, how do we reduce them," Wade said yesterday in a speech to a Toronto conference on patient safety.

Canadian Press Newswire
September 17, 2002
Canada must invest $50 million to identify, reduce medical errors: task force
TORONTO (CP) _ Canada needs to invest $10 million a year over the next five years to create a national institute to identify, track and find ways to reduce medical errors, says a special task force on patient safety.
''The whole idea is not just to measure them and throw up our hands, but rather to find ways to problem-solve and eliminate them,'' said Dr. John Wade, chair of the national steering committee on patient safety, which will announce 19 recommendations next week.

CIO Magazine
September 15, 2002
How to Win Friends and Influence Users

The Press Trust of India
September 15, 2002 Sunday
BOOK-DOCTOR
    Mirror, Mirror, Who Is The Best Doctor Of Them All...?
   New Delhi, Sep 15 "Almost half the patients with chronic illnesses do not get the treatment recommended by experts; 20 per cent get the wrong care and medical errors claim between 44,000 and 98,000 lives every year."
   When this is what happens in USA, one of the medically most-advanced countries in the world, one can very well imagine the case of India, where there is no dearth of horror stories caused by bad doctors.
   "These mistakes occur primarily because patients select the wrong doctor for their medical care. The best way to ensure the right patient care is to pick the right doctor," says a new book.

Congressional Testimony
September 10, 2002 Tuesday
Committee: House Ways and Means Legislation to Reduce Medical Errors
Statement of the Hon. Tommy G. Thompson, Secretary, of U.S. Department Health and Human Services
Testimony Before the Subcommittee on Health of the House Ways and Means Committee
Hearing on Legislation to Reduce Medical Errors
September 10, 2002
Good morning, Madam Chairwoman and members of the Subcommittee. I am honored to appear before you today to discuss ways the Federal government can help reduce medical errors and improve the safety of the health care services that Americans receive.
In the last few years the Department of Health and Human Services (HHS) has developed a coordinated set of initiatives to identify and reduce threats to patient safety and improve the quality of patient care. While these initiatives are important, they are only a beginning.
President Bush and I recognize that significant progress will only be achieved when the talents and energies of health professionals are fully engaged in improving the quality of care. We have been heartened by the recent emergence of several notable private sector patient safety initiatives. But much more needs to be done -- and can be done -- to eliminate the barriers that discourage health care providers from participating, voluntarily and enthusiastically, in local and regional patient safety and quality improvement efforts.

Congressional Testimony
September 10, 2002 Tuesday
Committee: House Ways and Means Legislation to Reduce Medical Errors
Statement of Herbert Pardes, M.D., President and Chief Executive Officer, New York-Presbyterian Health Care System
Testimony Before the Subcommittee on Health of the Committee on House Ways and Means
Hearing on Legislation to Reduce Medical Errors
September 10, 2002
Summary
New York-Presbyterian Hospital is one of the nation's largest academic medical centers and is a center of excellence in the use of information technology (IT). IT in the clinical setting can reduce medical errors and increase quality of care through a wise national investment policy. The Computer-based Patient Record (CPR) is at the center of a technology strategy that would reduce errors. A complete CPR is impossible without standards for interoperability in healthcare IT. Hospitals are functioning at or below margin and are hard pressed to pursue the necessary investments to establish appropriate systems. Two major steps are needed: a standard setting process to allow interoperability among diverse systems from different vendors; and federal reimbursement. Academic medical centers have the expertise and neutrality to lead this process in collaboration with industry and government. The interoperability provisions of H.R. 4889 advance the right approach. They call for the formation of a board of experts from every effected constituency to recognize existing standards and develop or validate new standards. However, another step is also needed. Congress needs to allow for the demonstration projects that will assure the efficacy, usability and scalability of standards. As technology is developed for millions of patients rather than thousands, or even tens of thousands, scalability becomes a major stumbling block.

The Commercial Appeal (Memphis, TN)
September 9, 2002 Monday Final Edition
HOMING IN ON HOSPITALS; SURVEY OF SKILLS DESIGNED TO HELP CONSUMERS MAKE BETTER CHOICES
    Memphis consumers and the employers who help underwrite their health care have a new tool to help decide where to turn for hospital care.
   The Memphis Business Group on Health has released results of its first survey of 17 area hospitals. It focused on whether hospitals used computerized prescribing, physician oversight of critically ill adult patients and each institution's experience with six difficult procedures, including heart bypasses and high-risk deliveries. All have been linked to improved patient safety and better patient outcomes.
   The survey found plenty of room for improvement.

National Journal's Congress Daily
September 09, 2002 Monday 10:30 am Eastern Time am
SECTION: HEALTH Debate On Medical Errors Continues
In addition to problems such as rising costs and up to 50 million people lacking health insurance, the U.S. healthcare system has another major problem - quality of care. The nation's physicians, hospitals and other providers may give some of the world's best care, but they also make mistakes and commit errors of judgment.
Legislation is now afoot to create medical error data banks. In the House and Senate, bills have been introduced to allow patient safety organizations to collect information voluntarily from health institutions and service providers on medical mistakes - and ways to avoid them.

Aviation Week & Space Technology
September 2, 2002
First-Responder Training Borrows CRM From Airline Industry
     Firefighters, emergency medical technicians and law enforcement personnel who comprise the initial responders to a terrorist incident are benefiting from a ''culture of safety'' concept developed and embraced by the U.S. airline industry.
    Training programs for these ''first responders'' are now based on cockpit resource management (CRM) procedures, which drastically reduced air carrier accidents attributable to human error. Adapting CRM principles and methods to emergency-response specialties will mitigate damage and casualties following a terrorist attack, because fewer mistakes will be made, government officials believe.
    The transfer of CRM knowledge from commercial air carriers to other segments of society started in the mid-1990s, but accelerated after the Sept. 11 terrorist attacks. Researchers in Switzerland and Texas have focused specifically on the health care field, because they found close parallels in aviation and medicine. Pilots and physicians, they discovered, have similar ' 'command styles.''

Alcohol Research Documentation, Inc. Journal of Studies on Alcohol
September 1, 2002
Iatrogenic effects of alcohol and drug prevention programs.
A CONSIDERABLE AMOUNT of media attention was recently paid to an Institute of Medicine report (Kohn et al., 2000) indicating that medical errors may result in 44,000 to 98,000 deaths in the U.S. each year. A more recent study reporting on the iatrogenic effects of medical care suggested that almost a quarter of hospital deaths were at least possibly preventable (Hayward and Hofer, 2001). Meanwhile, in the mental health literature, there have been relatively rare but well-known published accounts of negative treatment side-effects including increases in criminal behavior, violence, substance use, maladjustment, death and disease (Dishion et al., 1999; Gersten et al., 1979; McCord, 1978).
Common thinking regarding prevention and health promotion programs is that they are helpful, or perhaps benign at worst, but rarely if ever harmful (Whitaker, 2001). Is it possible that substance use prevention, like medicine and mental health treatment, occasionally results in unanticipated harmful outcomes? Some studies suggest this is so, with health promotion and prevention interventions, targeting behaviors as diverse as mammography use (Schwartz et al., 1999) and eating disorders (Mann et al., 1997), resulting in adverse impacts.

Medical Laboratory Observer
September 1, 2002
New bill would improve patient safety; Washington Report; Patient Safety and Quality Improvement Act
Washington remains concerned about the high rate of medical errors in the healthcare system. In an effort to improve the situation, a bipartisan group of senators recently introduced the Patient Safety and Quality Improvement Act.
The measure would enhance patient safety by encouraging voluntary reporting of information and raising standards and expectations for continuous quality improvements. The sponsors of the bill include Sens. Jim Jeffords, I-VT; Bill Frist, R-TN; John Breaux, D-LA; and Judd Gregg, R-NH.

Business Week
August 26, 2002
21: Minimal Medicine
Here's one of your worst medical nightmares. On June 5, Dean Monahan, a 42-year-old steelworker in Reading, Pa., was scheduled for an angiogram, a common medical procedure used to determine if plaque is building up in a patient 's arteries. Monahan had experienced some pain in his arm and neck while exercising, which could indicate a blocked artery. He checked into Reading Hospital & Medical Center at 7 a.m., the angiogram was performed at 11 a.m., his arteries were declared completely clear, and he checked out at 4.
By 6:30 that night, Monahan had a temperature of 103. He rushed back to the hospital, where the staff discovered that he had contracted pneumonia during his nine hours there. ''I was out of work for a month and flat on my back for a good 10 days,'' says Monahan. ''I see now how old people succumb to pneumonia. It really saps all your strength.''

The News-Press (Fort Myers, FL)
August 22, 2002 Thursday
Stephen E. Hooper
    Guest opinion
   Negligence of doctors reason for malpractice crisis
   What's the difference between God and a doctor?
   - God doesn't think he is a doctor.
   Recently Dr. John Donaldson, a pediatric otolaryngologist in Fort Myers, wrote a lengthy call to arms to his fellow doctors to lead the way toward tort reform. In his opinion, another "malpractice crisis" is upon us, brought about by those most notorious of all bogeymen, trial lawyers. Donaldson said doctors pay skyrocketing sums for malpractice insurance, with premiums recently doubling for some doctors, most notably obstetricians. Donaldson encourages them to get out of the practice altogether.

PR Newswire
August 22, 2002, Thursday
MICROMEDEX Expert Helps Emergency Nurses Reduce Medical Errors
MICROMEDEX, a part of The Thomson Corporation (NYSE: TOC; Toronto: TOC), announced today their effort to educate nurses on reducing medical errors at the Emergency Nurses Association Scientific Assembly in New Orleans. Rich Klasco MD, chief medical officer for MICROMEDEX, will share his medical and technological expertise Sept. 21 during his speech entitled "Therapeutic Misadventures: Adverse Drug Events and How to Avoid Them in the ED." He will highlight how to effectively integrate information technology into everyday workflow to dramatically decrease medical errors. "Fast pace and high acuity make emergency medicine the most highly charged setting for medical errors. When mistakes happen, they are devastating," said Klasco. "By combining knowledge with technology, we can effectively avoid patient harm and prevent many of the 44,000-98,000* American deaths caused by medical errors every year."

Spokesman Review (Spokane, WA)
August 20, 2002 Tuesday Spokane Edition
Patients play role in elevating hospital care;
    A 1999 Institute of Medicine report estimated that 44,000 to 98,000 people die in U.S. hospitals each year as the result of lapses in patient safety.
    Hospitals are working to improve, but there also are steps every patient can take to prevent becoming an error statistic.
    The federal Agency for Health Care Research and Quality offers this list:
    * Speak up if you have questions or concerns. Choose a doctor with whom you feel comfortable talking about your health and treatment. Take a relative or friend with you if this will help you ask questions and understand the answers. It's OK to ask questions and to expect answers you can understand.

The Clarion-Leader (Jackson, MS)
August 18, 2002 Sunday
Everybody playing the blame game: It's them, not us!
    By Jerry Mitchell
   Clarion-Ledger Staff Writer
   Looking for someone to blame for some doctors leaving Mississippi in the wake of rising litigation and medical malpractice premiums?
   Take your pick among the following possible culprits:
   Doctors
   A 1999 study by the Institute of Medicine took the results of two previous studies about hospital admissions in three states and deduced that at least 44,000 and perhaps as many as 98,000 Americans die in hospitals each year as a result of medical errors.
   That would make medical errors the eighth leading cause of death in the United States, ahead of motor vehicle accidents, breast cancer or AIDS.
   "Those are just the people who die," said Jackson lawyer Shane Langston, past president of the Mississippi Trial Lawyers Association.       "That doesn't even count the many more people who are injured. Medical malpractice is one of the leading causes of death in this country."

Medical Post
August 13, 2002
To catch an error: without good protective legislation, reporting medical mistakes is risky. So safety experts are focusing on close calls and other techniques to cut clinical errors
There's no doubt health care is a high-hazard industry. But most agree patient safety concerns have not been addressed with the same rigour as in other high-risk fields such as the aviation and nuclear industries.
According to the U.S. Institute of Medicine, between 44,000 and 98,000 deaths in the U.S. are the result of adverse events each year.
Six years ago, three surgeons at the Wellesley Central Hospital in Toronto monitored complications in the general surgical service over a two-month period. Of the 192 inpatients treated, 18% had events considered to be potentially attributable to error.

Palm Beach Post (Florida)
August 11, 2002 Sunday FINAL EDITION
HOW DEADLY IS A MEDICAL OOPS?
Did you hear the one about the orthopedic surgeon in Boston who left a patient with an open incision in his back for a half-hour while he went to the bank? The patient is fine after spine surgery. Massachusetts regulators have suspended Dr. David Arndt's medical license.
That's hardly an example of the "medical errors" we've heard about - amputating the wrong leg, for example, or taking out the wrong patient's appendix. Rather, it's inexcusably irresponsible behavior. But it pricked my memory to check on what's been done since the Institute of Medicine published its controversial report on medical errors in November 1999.

Press & Sun-Bulletin (Binghamton, NY)
August 10, 2002 Saturday
GUEST VIEWPOINT - Tort reform won't improve health care
    In a recent article certain "health care officials" called for "tort reform legislation," stating that "warping litigation," "frivolous lawsuits" and "overzealous" trial lawyers have caused high medical malpractice insurance premiums that "will send physicians fleeing."
   The issues, which affect doctors, victims, voters, jurors and patients, deserve informed debate.
   According to a National Academy of Sciences report, medical errors in hospitals kill between 44,000 and 98,000 Americans each year -- more than highway accidents, breast cancer or AIDS. "These stunningly high rates of medical errors -- resulting in deaths, permanent disability, and unnecessary suffering -- are simply unacceptable in a medical system that promises first to 'do no harm,'" said one of the authors of the report.

Rocky Mountain News (Denver, CO)
August 8, 2002 Thursday Final Edition
GLOBE
    RETURNING HOME
   The body of Daniel Pearl, the Wall Street Journal journalist kidnapped Jan. 23 and later slain by Islamic militants, left Karachi, Pakistan, early today en route to the United States.
   Associated Press
   READY FOR ROUND 2
   "If the president is willing and if my wife approves, and if the doctor say it's OK, then I'd be happy to serve a second term.

The Dallas Morning News
August 7, 2002, Wednesday
Businesses explore how insurance costs can help meet strategic goals
    WASHINGTON _ For decades, business executives have signed ever-larger checks to buy health care for their employees. Insurance coverage was seen as a consumptive good they had to purchase for their workers.
   But now businesses are becoming tougher customers. Facing a surge in health costs, they are increasingly applying the same scrutiny to health care that they do to important, strategic investments.
   "And the next question they ask is, 'What are they getting from their investment?'" said Walter Stewart, vice president of research and development at AdvancePCS, an Irving, Texas-based health management company.

Scripps Howard News Service
August 07, 2002, Wednesday
Guarding against wrong-side surgery
    Wrong-side surgery is an operation done by mistake on the healthy side of the body, rather than the diseased side.
   Amid nationwide concern over medical errors, wrong-side surgery incidents often get lots of attention.
   That's because wrong-side surgery is such an obvious mistake.
   A Florida brain surgeon earlier this year started cutting into one side of a patient's head before realizing that he really meant to do the other side. A Michigan jury in April awarded $500,000 to a boy whose urologist twice operated on the wrong kidney. Patients undergo surgery to have a painful right knee joint replaced, and wake up with bandages on the left knee.

Providence Journal-Bulletin (Rhode Island)
August 4, 2002, Sunday All Editions
Hospitals wean doctors from handwritten record-keeping
* Overcoming doctors' resistance, Lifespan turns to computers for safety and efficiency.   * * *
   PROVIDENCE - It's an April morning in the intensive-care unit at Rhode Island Hospital, and doctors are puzzling over what afflicts a 58-year-old man who showed up the night before complaining of dizziness, weakness, diarrhea, and fever.
   Dr. Mitchell M. Levy, the medical director, and a gaggle of residents have gathered around three computer terminals -- two wireless laptops on small rolling desks and a stationary PC.
   Although these computers look no different from those on office desks everywhere, they're actually something of an oddity in this high-tech medical unit. The health-care industry, typically arthritic when it comes to change, has been slow to mine the potential of information technology.

BestWire
August 02, 2002
Best's Review: New Technology Might Cut Medical Errors, Med-mal Claims
OLDWICK, N.J. (BestWire) - Medical errors cause the deaths of thousands of people each year, and now providers are using technology to prevent these mistakes, according to the article, "Make No Mistakes," in the August issue of Best's Review. Preventable medical errors are the eighth-leading cause of death in the United States, resulting in 44,000 to 98,000 deaths each year. Medical errors result in more deaths annually than vehicle accidents, breast cancer or AIDS, according to the Institute of Medicine. Now, several hospitals and health-care facilities are installing physician order-entry systems to help reduce these numbers. The systems allow providers to access computerized health-care information, such as prescriptions and renewals, clinical laboratory results and patient histories, via a hand-held device. Medical errors stem from a variety of situations, including illegible handwriting, drug overdoses from decimal-point errors and drug interactions. The computerized order-entry systems are designed to reduce the time it takes to get orders to a pharmacy, but also to provide legible and easy-to-understand orders. Some users of the system are praising its ability to compare orders against dosing standards, check for allergies or interactions with other medications and warn physicians about potential problems. The systems are touted to reduce medical errors by 50%. Although it's too soon to predict what effects the computerized order-entry systems will have on the industry, recent legal rulings have sided against physicians in cases where technology solutions could have prevented medical errors. "Customers now have a real interest in the technology's impact on medical malpractice, and we're currently at the tipping point where technology has caught up with the need for real solutions in this area," said Glen Tullman, chief executive officer of Allscripts Healthcare Solutions, a manufacturer of wireless hand-held clinical-automation software and computerized order-entry systems.

The Baltimore Sun
August 2, 2002 Friday FINAL Edition
Hospital error reporting rule under review; State drafts regulation for mandatory reports; 'It is the right thing'; Measure would require notification of family
Maryland may soon require hospitals to report all medical errors that seriously harm patients - a measure that regulators hope will curb mistakes like the chemotherapy overdoses recently given to two patients at the Johns Hopkins Children's Center.
The state health department has been drafting the mandatory-reporting regulations for several months and hopes to have them in place by early next year, an official said yesterday.
Carol Benner, director of the state's Office of Health Care Quality, said she expects the rules will require hospitals to report all mistakes that cause serious injury or death or require corrective treatment.
In each case, hospitals would have to analyze what went wrong and indicate what they were doing to prevent similar mistakes from occurring.

The Baltimore Sun
August 1, 2002 Thursday FINAL Edition
Boy lost hearing in Hopkins overdose; 'Systems broke down,' Md. oversight official says
A 2 1/2 -year-old boy became deaf after receiving an overdose of cancer chemotherapy two months ago at the Johns Hopkins Children's Center, the state health department said yesterday.
The child, who was given twice the correct dose on three successive days, was one of two pediatric cancer patients given accidental overdoses in late May, the agency said. In the other case, which involved a young girl, the dose was corrected after one treatment and before any harm was done.
Carol Benner, director of the state's Office of Health Care Quality, said hearing loss is a known risk of the medication, so it was not certain whether the child's deafness was a result of receiving too much. But she said the overdose was a serious and tragic mistake that significantly increased the risk of hearing loss.

Best's Review
August 1, 2002
Make no mistake: a new hand-held device for physicians is predicted to reduce the number of medical errors by up to 50%. Will it also mean lower medical malpractice premiums and claims? Technology: Medical Errors.
     Between 44,000 and 98,000 patients die from medical errors each year. Now insurers are keeping a watchful eye on technology designed to help prevent these fatal mistakes.
    Preventable medical errors--the eighth-leading cause of death in America--result in more deaths annually than vehicle accidents, breast cancer or AIDS, according to the Institute of Medicine. Several hospitals and health-care facilities across the nation are working to reduce these dramatic numbers by installing physician order-entry systems, which allow providers to access computerized health-care information--such as prescriptions and renewals, clinical laboratory results and patient histories--via a hand-held device.
    Since this technology is only now gaining in popularity, insurers say it is too soon to predict what effects computerized order-entry systems will have on the industry. Many are paying close attention, however, to their potential to slash health-care costs and reduce medical malpractice premiums and claims as a result of fewer medical and medication errors.

Health Management Technology
August, 2002
A Winning Combination
Three years ago, the Institute of Medicine (IOM) reported that medical errors result in at least 44,000 deaths each year -- more than deaths from highway accidents, breast cancer or AIDS. That report, and others which placed serious errors as high as 98,000 annually, served as a wake-up call for healthcare providers such as the CareGroup Healthcare System Inc., a Boston-area healthcare network that is the second largest integrated delivery system in the northeastern United States. With annual revenues of $ 1.2B, CareGroup provides primary care and specialty services to more than 1,000,000 patients.
CareGroup combined wireless technology with the Web to create a provider order entry (POE) system designed to reduce the frequency of costly medical mistakes. The POE infrastructure includes InterSystems Corporation's CACHE database, Dell Computer C600 laptops and Cisco Systems' Aironet 350 wireless networks.

RN
August 1, 2002
Patient Safety bills: voluntary reporting of medical mistakes; Professional Update; Brief Article
A voluntary reporting system for medical mistakes is at the heart of legislation recently introduced in both the U.S. House and Senate.

The Commercial Appeal (Memphis, TN)
July 28, 2002 Sunday Final Edition
RESIDENTS LIKE EASIER SCHEDULE; HOSPITALS FEEL PINCH
    For doctors like Ben Zarzaur, who is completing his surgery training, coming national rules that will limit the workweek to 80 hours, shifts to 24 hours and guarantee a day off every week represent a kinder, gentler schedule.
   For hospitals like the Regional Medical Center at Memphis that rely heavily on the young physicians, the rules pose a challenge. If doctors in training, known as residents, aren't around to care for patients, hospital administrators will have to spend more to hire staff or expand training programs.
   And faculty warn that the new rules might prompt educators to add another year to some training programs.

American Health Line July 26, 2002 Friday MEDICAL ERRORS: FDA CONSIDERING MANDATORY BAR CODE SYSTEM
The FDA today is holding a public hearing to discuss requiring that all hospitals affix barcodes to patient IDs and prescription drug containers in order to prevent "thousands of ... deaths each year," the Wall Street Journal reports. A 1999 study by the Institute of Medicine found that "preventable medical errors" in hospitals cause between 44,000 and 98,000 deaths each year.

Business Wire
July 24, 2002, Wednesday
ALARIS Medical Advances Medication Safety With Enhanced Technology; New Software Release Expands Safety in the Operating Room and Additional Areas of Care

   ALARIS Medical Inc. (AMEX:AMI) announced today that its wholly owned subsidiary, ALARIS Medical Systems Inc., has released an enhanced version of its Guardrails(TM) Safety Software for use with the MEDLEY(TM) Medication Safety System.
   The new features of the Guardrails(TM) Software are designed to better meet the unique needs of anesthesiologists.
   The Guardrails(TM) Safety Software, which is the foundation of ALARIS Medical Systems' safety solution, is designed for intravenous medication error prevention. It provides a unique automatic safety net for infusion programming by focusing on medication error management at the critical point of infusion delivery to the patient. The software helps protect patients from infusion programming errors by allowing institutions to configure unique care area rules, or profiles, with pre-defined drug dose limits and delivery parameters to meet the specific needs of multiple patient care areas.

U.S. News & World Report
July 22, 2002
Speaking up for safety
CONCORD, N.H.
--On the fifth of July, Herb Olson started his day with a dozen people crammed into his room at Concord Hospital. He'd had a triple heart bypass four days before, which in most hospitals would mean that his day would be punctuated at odd hours by visits from doctors and nurses. But not here. Instead, everyone who had something to do with the 70-year-old's care--nurses, a pharmacist, physical therapists, and even the chaplain--convened, as they had each morning, to talk with him and with each other. Barbara Jolin, a nurse and care coordinator, read off Olson's schedule from the previous day and asked if all had gone as planned. The dietitian said she would visit later to explain postoperative cui-sine when Olson's wife was there. The pharmacist read off a list of medications and answered Olson's question about how enteric-coated aspirin protects the stomach lining. The physical therapist said she'd be in to help him shower. "Any glitches?" asked Anne Nason, a nurse practitioner who leads the group.

Idaho Falls Post Register (Idaho Falls, Idaho)
July 17, 2002 Wednesday
Gingrich pushes health-care Web site
- Governors hear ex-HouseSpeaker
BOISE - You stick a debit card into an automated teller machine and it provides detailed information about your finances.You go to a travel Web site and learn about motel rates and the availability of flights anywhere on the planet.
So why can't the same apply to health care?
Why is the system so complicated?

Federal Document Clearing House Congressional Testimony
July 17, 2002 Wednesday COMMITTEE: HOUSE ENERGY AND COMMERCE IMPACT OF LITIGATION ON HEALTHCARE ACCESS
Statement of Travis Plunket Legislative Director Consumer Federation of America
Committee on House Energy and Commerce Subcommittee on Health
Harming Patient Access to Care: The Impact of Excessive Litigation

July 17, 2002
Good morning. I am Travis Plunkett, legislative director for the Consumer Federation of America. CFA is a non-profit association of more than 290 organizations founded in 1968 to advance the consumer interest through advocacy and education. Ensuring the provision of fairly priced and adequate insurance has been one of our core concerns since CFA's inception.
I would like to thank Chairman Bilirakus, Ranking Member Brown and the other members of the Subcommittee for the opportunity to offer our comments on this extremely important issue. For the third time in less than thirty years, Congress and state legislators across the country are grappling with the problem of fast-rising medical malpractice rates. Insurers insist that a sharp increase in large, unwarranted jury verdicts is to blame for the crisis. As a result, lawmakers on this Subcommittee and in a variety of states are considering legislation to place further limits on the legal rights of Americans who have been harmed or killed by medical malpractice.

Orlando Sentinel (Florida)
July 16, 2002 Tuesday, FINAL
MALPRACTICE CRISIS?; WHAT MALPRACTICE CRISIS?;
Thursday's "My Word" column, "A malpractice crisis driving our doctors away," was based purely on anecdotal arguments and lacked any factual or empirical support.
In fact, there is no medical-malpractice-litigation "crisis." The rising insurance rates are the direct result of a profit-driven insurance industry suffering major losses in a declining stock market, coupled with an exceptionally high number of medical errors.

Marketing Health Services
JULY 2002
Protecting patient safety
    Medical errors cause between 44,000 and 98,000 hospital deaths annually and cost the nation $ 29 billion in added healthcare costs -- an alarming statistic that's not lost on consumers. A recent survey co-sponsored by The National Patient Safety Foundation, Partnership for Patient Safety, Premier Inc., and VHA Inc. found that a full 92% of respondents believe more could be done to adequately address and reduce medical errors.
   Conducted at a national patient safety symposium, the survey found that only 16% of respondents believe the healthcare community is effectively using technology to assist with patient safety initiatives. However, only 44% of the 118 survey respondents believe Congress or the federal government should be involved in national patient safety efforts.
USA TODAY
July 15, 2002, Monday, FINAL EDITION
High-volume medical care provides best results
         Consumers are right to fear errors and poor-quality medical care, and doctors and hospitals are scrambling to improve in these areas. But there is a powerful practical step people can take: get care from a "high volume" medical provider, especially if surgery, treatment for a serious illness or hospitalization is involved.
         A growing body of research confirms that doctors and hospitals that do more of a specific procedure tend to do it better.
         A study published in The New England Journal of Medicine in April, for example, found that hospitals that performed a high volume of certain surgical procedures had death rates lower than those of hospitals that performed low volumes of the same procedures. The researchers looked at 14 different types of surgery and found that volume mattered for all of them.

July 14, 2002
Sunday SECOND EDITION
Asking healthy questions; Businesses explore how insurance costs can help meet strategic goals; What are they getting from their investment?'
WASHINGTON - For decades, business executives have signed ever-larger checks to buy health care for their employees. Insurance coverage was seen as a consumptive good they had to purchase for their workers.
But now businesses are becoming tougher customers. Facing a surge in health costs, they are increasingly applying the same scrutiny to health care that they do to important, strategic investments.
"And the next question they ask is, 'What are they getting from their investment?'" said Walter Stewart, vice president of research and development at AdvancePCS, an Irving-based health management company.

Independent on Sunday (London)
July 14, 2002, Sunday
Come with Me to the Ivf Clinic and I'll Show You How Easy it Is to Screw Up; Cole Moreton Wasn't the Slightest Bit Surprised to Hear That a White Woman Had Given Birth to Black Twins after a Medical Error. He's Been Through the Whole Ivf Process, and Found it to Be a Cruel and Chaotic Game of Chance
         Black babies born to a white mother? A huge shock to the parents and a national scandal, but no surprise to those of us who have been through IVF treatment on the NHS. We could see that one coming. "There is very little chance of you having a baby here," a consultant at the local hospital told my wife and me. His fertility unit had just enough money to keep going but not enough to make women pregnant. The ultrasound clinic was always overbooked or closed, so scans were taken days after it was too late, and there was nobody to read them because the one full- time nurse was on maternity leave. We could go on trying to get treatment, he said, but there was little point. "Unless, of course, you have any money."
As Mrs A, birth mother to the black twins, has found, it is risky trusting your fertility to the NHS. Overworked people in underfunded units make mistakes - although exactly what went wrong in this case, and the consequences, will be the subject of a court hearing in October.
Scotland on Sunday
July 14, 2002, Sunday
LOTTERY OF LIFE
         PROFESSOR Robert Edwards' mood is sombre. Sitting in his office in rural Cambridgeshire, the IVF pioneer is trying to take in the terrible news he has just heard.
          Nearly a quarter of a century after the eminent scientist helped bring Louise Brown - the world's first test tube baby - into the world, the revolutionary infertility technique he pioneered is once again under the microscope.
         Edwards has just learned that a white mother who had undergone in vitro fertilisation has given birth to black twins as a result of a blunder at an NHS clinic, and the sadness is etched on his face. His mood is in stark contrast to the elation he felt shortly before midnight on July 25, 1978, when Louise made history and brought new hope to thousands of infertile couples who believed they could never have children. Nowadays, IVF is successful in around 15 per cent of cases. Around a fifth of IVF treatment is funded by the NHS and couples pay around 3,000 pounds for a course of private treatment.

CBS MarketWatch
July 12, 2002 Friday
Pharmacist shortage raises concern about medical errors
LOS ANGELES (CBS.MW) - The nation's growing pharmacist shortage is raising concerns that prescription errors will increase and counseling will decline as stressed druggists scramble to handle heavier workloads.
About 7,000 chain-pharmacist positions were vacant at the start of this year, putting added pressure on existing staff and heightening error risks. Medication errors, occurring in or out of hospitals, account for more than 7,000 U.S. deaths annually, according to the Washington, D.C.-based Institute of Medicine.

Investor's Business Daily
July 11, 2002, Thursday COMPUTER PROGRAMS AND SYS. Mobile, Ala Tech Firm Beats Odds With Successful Debut Recent IPO Goes Well Fiscal caution is cited as one reason the Street has embraced its stock

How do you take a tech firm public in today's market? Even if your balance sheet is good, Wall Street is bound to be jittery. It helps if you serve a reliable industry. That's what's worked for Computer Programs & Systems Inc. The company makes integrated systems designed to help hospitals and clinics with such tasks as billing, management and prescriptions. CPSI had its initial public offering in mid-May. The stock has gone up and down, but it's still fared better than the rest of the market. It trades near 21 after opening at 17. Fiscal caution might be one reason CPSI has gotten a decent reception from investors. Analyst James Kumpel of Raymond James, which co-managed the IPO, says the firm records very little income until it's actually in the bank. "They don 't book any revenue at contract signing," he said. "Eighty percent of revenue comes only after they've installed the system." In addition, CPSI has no debt and doesn't spend much cash. The company's never made a buyout in its 23-year history. That keeps it a lot smaller than other public companies in its field, such as Cerner Corp. and IDX Systems Corp. But CPSI's approach has its pluses. For one thing, it flies under the radar of the larger firms by serving small hospitals with about 100 beds each. Smaller hospitals often have only one person on the information technology staff - if that - so CPSI can move in and essentially take over.

Modern Healthcare
July 8, 2002, Monday
Use the right stuff the right way; We have the technology--now we need to apply it to improve the quality of care
The decision late last month by HCA and Atlanta's Promina Health System to join the Leapfrog Group in its effort to reduce medical errors and improve the quality of care in hospitals underscores the importance of the information technology revolution sweeping through the American healthcare industry.
This revolution is responding to the basic problem that medical knowledge, skills, drugs and devices have advanced faster than our ability to deliver them to patients safely, effectively and efficiently. That lesson was made shockingly clear by the now-famous reports from the Institute of Medicine. Both studies outlined how paper-based clinical and administrative procedures-many of which have been in place and practiced for decades throughout our provider facilities-are causing inefficiency, adding cost and most alarmingly contributing to preventable medical errors that are estimated to kill from 44,000 to 98,000 people each year. Even using the lower figure, the lost lives equate to more than one World Trade Center disaster every month.

Toronto Star
July 8, 2002 Monday Ontario Edition
The hidden epidemic
AS POLITICIANS bicker about our health-care crisis, they are virtually ignoring a lethal but controllable threat to Canadians' lives > inadequate patient safety. Funding and accessibility are important, but who would be eager to seek health care if they knew that "the treatment" could likely injure or kill them? In the United States, former president Bill Clinton took urgent public policy steps to improve patient safety, right after the public learned that 44,000 to 98,000 patients die annually from preventable medical error in American hospitals alone. That makes medical error the eighth leading cause of death, outranking AIDS (16,516), breast cancer (42,297), and motor vehicle accidents (43,458). If the situation were the same in aviation, there would be a wide-body jet crash every day or two, killing everyone on board.

The Oregonian
July 6, 2002 Saturday SUNRISE EDITION
Medical Errors a Serious Problem
Colin R. Cave refers to the awards given to the victims of medical errors as an "out-of-control liability climate -- jackpot justice" (Commentary, July 2). Instead of creating sound bites to deal with the issue, perhaps he should go to the source of the problem and deal directly with the issue of medical errors.

Vancouver Business Journal (Vancouver, WA)
July 5, 2002 Friday
Hospitals enter digital age: Technology building momentum
Saving lives via accurate and timely information is pushing hospitals across the nation to embrace information technology. Setting the benchmark for many hospitals is the November 1999 U.S. Institute of Medicine report, To Err Is Human: Building a Safer Health System. It asserts that the U.S. needs a "health care system that makes it easy to do things right and hard to do them wrong." According to the report, medical errors kill some 44,000 people in U.S. hospitals each year.

Business Journal
July 5, 2002
Hospitals enter digital age: Technology building momentum.
Byline: Sheree Fitzpatrick
Saving lives via accurate and timely information is pushing hospitals across the nation to embrace information technology.
Setting the benchmark for many hospitals is the November 1999 U.S. Institute of Medicine report, To Err Is Human: Building a Safer Health System. It asserts that the U.S. needs a "health care system that makes it easy to do things right and hard to do them wrong." According to the report, medical errors kill some 44,000 people in U.S. hospitals each year.

AORN Journal
July 1, 2002
Myriad topics addressed during education sessions held at Congress: Sunday, April 21, to Thursday, April 25, 2002; Education Sessions.
Attendees at the 49th annual AORN Congress had a wide variety of education sessions to choose from. Topics ranged from evidenced-based practice and plastic surgery to Creutzfeldt-Jakob disease (CJD). Special sessions designed just for managers and students also drew large crowds. Following are overviews of just a few of the exciting sessions presented this year.
EVIDENCE-BASED PRACTICE KEY TO FIGHTING SURGICAL SITE INFECTIONS
As health care workers continue to battle newly resistant and increasingly resistant organisms, they must turn to standard precautions and recommended practices to reduce patient infection rates and their personal risk. That was the message Susan Renee Guerra, RN, MN, CNAA, CNOR, and Mary Lynne Weemering, RN, MSN, CNOR, delivered in their presentation titled "Breaking the Chain of Infection in the OR."

The BBI Newsletter
July 1, 2002
Nursing shortage and patient safety are focal points at AORN; BBI at the Association of PeriOperative Registered Nurses; conference on nursing shortages and patient safety
ANAHEIM, California -- Nursing shortages and patient safety were underlying currents evident during this year's Association of periOperative Registered Nurses (AORN; Denver, Colorado) annual congress. So much so that both established and startup medical companies came forward to help. Major commitments were made by Johnson & Johnson (J&J; New Brunswick, New Jersey) and Sandel Medical Industries (SMI; Chatsworth, California). J&J's initiative will have long-term results. SMI aims for the short term.
In February, J&J launched a national recruiting campaign, the Campaign for Nursing's Future, to help reduce the nursing shortage. Developed in cooperation with national nursing organizations, spending on the campaign is estimated to exceed $ 20 million over the next two years. It addresses a shortage of registered nurses now estimated at 126,000 in hospitals and projected to increase to more than 400,000 in all healthcare facilities by 2020. According to 75% of Americans questioned in a recent nationwide poll, the nursing shortage raises concerns for the future of healthcare.

Paddock Publications Daily Herald (Arlington Heights, IL)
July 1, 2002
Hospitals work to prevent the mistakes tha can kill; News
Byline: Ames Boykin Daily Herald Staff Writer
Hippocrates would be proud.
Confronted with estimates that 7,000 people a year are killed by medication errors, more hospitals have become committed to remedying problems that contribute to such deadly mistakes by following the tenets set by the Greek physician responsible for the doctor's code of ethics.
Alexian Brothers Medical Center in Elk Grove Village is among them - under the cloud of a $ 6.5 million judgment for the fatal mistake of giving the wrong medication to a patient.
Alexian Brothers and Lake Forest Hospital are two Chicago-area hospitals that have joined the Boston-based Institute for Healthcare Improvement for the "Quantum Leaps in Patient Safety" project, aimed at minimizing situations that could lead to medication errors.
Two other Illinois hospitals, in Peoria and Sterling, are part of the program along with about 50 hospitals in North America and Sweden.

Executives Journal of Healthcare Management
July 1, 2002
Perceived barriers to medical-error reporting: an exploratory investigation.
EXECUTIVE SUMMARY
Medical-error reporting is an essential component for patient safety enhancement. Unfortunately, medical errors are largely underreported across healthcare institutions. This problem can be attributed to different factors and barriers present at organizational and individual levels that ultimately prevent individuals from generating the report.
This study explored the factors that affect medical-error reporting among physicians and nurses at a large academic medical center located in the midwest United States. A nominal group session was conducted to identify the most relevant factors that act as barriers for error reporting. These factors were then used to design a questionnaire that explored the likelihood of the factors to act as barriers and their likelihood to be modified. Using these two parameters, the results were analyzed and combined into a Factor Relevance Matrix. The matrix identifies the factors for which immediate actions should be undertaken to improve medical-error reporting (immediate action factors). It also identifies factors that require long-term strategies (long-term strategy factors) as well as factors that the organization should be aware of but that are of lower priority (awareness factors).
The strategies outlined in this study may assist healthcare organizations in improving medical-error reporting, as part of the efforts toward patient-safety enhancement. Although factors affecting medical-error reporting may vary between different organizations, the process used in identifying the factors and the Factor Relevance Matrix developed in this study are easily adaptable to any organizational setting.

Marketing Health Services
2002
Summer Protecting patient safety
Medical errors cause between 44,000 and 98,000 hospital deaths annually and cost the nation $ 29 billion in added healthcare costs -- an alarming statistic that's not lost on consumers. A recent survey co-sponsored by The National Patient Safety Foundation, Partnership for Patient Safety, Premier Inc., and VHA Inc. found that a full 92% of respondents believe more could be done to adequately address and reduce medical errors.
Conducted at a national patient safety symposium, the survey found that only 16% of respondents believe the healthcare community is effectively using technology to assist with patient safety initiatives. However, only 44% of the 118 survey respondents believe Congress or the federal government should be involved in national patient safety efforts.

Medical Malpractice Law & Strategy
July 2002
Practice Tip; Disclosing Unanticipated Medical Outcomes To Patients: Striking the Balance
How should health care providers handle disclosures of unanticipated medical outcomes in light of the recent standards promulgated by the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO)? The first part of this two-part article considers the circumstances triggering disclosure. Suggestions are made regarding general guiding principles that should be followed--most of which should already be established practice for all health care providers.
The second part will emphasize the issue of the confidentiality that attaches to hospital reviews of certain adverse events and of provider medical care in general. Such reviews, and the documents and information gathered thereby, are often protected by state statutes regarding quality assurance and peer review activities. The process of disclosing unanticipated medical outcomes to patients, even under the new JCAHO standards, should not undermine these protections. Heightened awareness of the applicable laws through training regarding the JCAHO standards and adherence to certain recommended guidelines and hospital investigative procedures, can ensure the applicability and viability of those legislative protections.

Packaging (Australia)
July 2002
Improved tracking may mean new RSS barcodes on drug packaging
IN the United States, the drug regulatory body the FDA is close to announcing new regulations for the improved tracking of drugs and medicines.
This will require new barcodes on drug packs, including very small unit-of-use pack sizes. Observers says this will require new types of barcodes, plus new scanning and printing investment for pharmaceutical packaging converters, but the biggest problem will be finding room on the packs for the new codes.

Pharmaceutical Executive
July 1, 2002
The new Era of risk management: pharma companies will have to conduct additional studies to establish a product's safety; Product Development.
FDA has issued the industry a new charge--pay closer attention to risk management. Now that prescription drug user fees have helped the agency approve candidates more rapidly, FDA has returned to its basic mandate: assuring that marketed pharmaceuticals are safe. In the past, that meant clear labeling with adequate directions and warnings based on clinical trials. The agency now believes that product safety extends beyond warning labels and wants to ensure that prescriptions are used safely as well. As a result, it is asking the pharma industry to demonstrate products' safety before approval and to further control their use after approval.
First, it is important to understand what "risk management" means today. Traditionally, pharma companies have mitigated risks by assessing safety throughout clinical trials and through post-marketing surveillance. Product labels have always specified the parameters for safe use, promotional communications have been limited to approved indications, and fair-balance statements have conveyed the meaningful risks. Those things have not changed. Now, however, FDA wants greater assurances that pharmaceuticals will be used as safely as possible. As Deputy FDA Commissioner Lester Crawford recently said, "There was a time when we put the drug out there and didn't worry much about it. That is changing."

National Public Radio (NPR)
SHOW: Weekend All Things Considered (8:00 PM ET) - NPR
June 30, 2002
Sunday Dr. Bob Wachter on a new series of case studies on medical mistakes
KORVA COLEMAN, host:
Three years ago a government report blamed hospital errors for the deaths of 44,000 people every year. While doctors do err, professional medicine usually is mum about treatment mistakes. This month the Annals of Internal Medicine has published the first in a series of case studies examining breakdowns in the hospital system and ways to learn from these mistakes. The series was conceived by Bob Wachter, a physician with the Department of Medicine at the University of California at San Francisco. (Department of Medicine, University of California at San Francisco)

Tucson Citizen
June 28, 2002
Friday OUR OPINION
Explanations - no comfort in hospital deaths
It's troubling to learn that Tucson Medical Center has been cited by state regulators in connection with nursing errors that caused or contributed to the deaths of five patients.
And it's even more troubling TMC defends itself by asking the public to view the matter in a broader context - that such mistakes happen in hospitals throughout the country.
Indeed they do, but this only makes most folks a bit more sick to their stomachs.

Tucson Citizen
June 27, 2002
Thursday TMC cited as nursing errors tied to 5 deaths
State investigators find violations in state and Medicare standards in mistakes made using oxygen tanks, a tube and a cardiac monitor. By ANNE T. DENOGEAN
Tucson Medical Center was cited last week by the state for violations in cases where nursing mistakes contributed to the deaths of five patients over the last two years.
Errors were made in the use of oxygen tanks, an oxygen tube and a cardiac monitor, directly causing the death of an otherwise healthy elderly man recovering from knee surgery and contributing to the deaths of four other seriously ill patients, state health department officials said.
TMC officials do not dispute that mistakes were made, but said they hope the public would understand the broader context and not single TMC out for criticism.
"In hospitals throughout the country, human errors are made from time to time, and the real important matter is what is done if a human error is made," said Jack Jewett, TMC's vice president for public policy.

Tulsa World
June 27, 2002
Thursday Physician, rest thyself; New rules tell residents to work less
Before medical students and residents start their own private practices, they need lots of practice.
Getting practice at the practice of medicine has been done for hundreds of years with young doctors helping human patients under the direction of an experienced doctor.
Commonly, they could work more than 120 hours per week, including 36-hour shifts. Note that there are only 168 hours in a week.
Now the American Medical Association and the Accreditation Council for Graduate Medical Education have adopted new policies limiting residents to work no more than 80 hours a week and no more than 24 hours at a time. The American Osteopathic Association board will discuss resident hours at its July 19 meeting.

The Washington Post
June 25, 2002, Tuesday, Final Edition
For Best Results, Select Hospital With Care -- and Early
When the time comes for an operation or other serious medical treatment, most of us exercise very little choice in the matter, heading to whatever hospital our doctor or managed care plan sends us. But a new guide published last week could change that by providing access to information about hospitals' quality and performance. The Consumers' Guide to Hospitals, published by the nonprofit D.C.-based Consumers' Checkbook group, encourages readers to select the hospital that will provide their care before others make the decision for them. "Hospital choice is a very important issue to people -- especially these days with all the stories out there about hospital mishaps and drug errors," said the guide's lead author, Robert Krughoff, the founder of the Checkbook group. Krughoff notes that, according to the Institute of Medicine of the National Academy of Sciences, at least 44,000 patients die each year in the United States as a result of preventable medical errors. "You can be instrumental in making sure that doesn't happen to you," he said. To assist readers in doing that, the 360-page guide, published last week, compares 4,500 acute care hospitals -- virtually every such facility in the United States -- in terms of risk-adjusted death rates (overall as well as for particular conditions), surgical outcomes, physician ratings and scores on reviews by the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), the nation's chief standards-setting and accrediting body in health care.

Health & Medicine Week
June 24, 2002 RISK MANAGEMENT: AORN announces patient safety initiative
The incidence of medical errors resulting in patient death is an issue of critical importance. In its 1999 study entitled, "To Err is Human: Building a Safer Health System," the Institute of Medicine reported that 44,000 to 98,000 deaths occur annually as a result of medical errors, including medication errors, surgical mistakes, and surgical complications. According to the report, it is estimated that the total national cost for medical errors is between $8.5 and $17 billion annually.

The Virginian-Pilot(Norfolk, Va.)
June 23, 2002 Sunday Final Edition
OPERATING BEHIND CLOSED DOORS
Glenn Gunter was hemorrhaging, and no one knew how to stop it.
Three weeks after the Virginia Beach man underwent obesity surgery, his life seemed to be ebbing away.
His deterioration began the moment he awoke from the operation in May 1990 barely able to breathe. Within days, his lungs partially collapsed, and he became feverish. Destructive acids and bacteria began leaking from a gap at the place where his stomach was stapled.

The Advocate (Baton Rouge, LA.)
June 21, 2002, Friday METRO EDITION
AMA backs 80-hour limit for residents to cut errors
CHICAGO - The American Medical Association endorsed a new 80-hour-a-week work limit for medical residents Thursday to try to keep doctors-in-training from becoming so bleary-eyed they hurt themselves or their patients.
Many doctors-in-training put in more than 100 hours a week and sometimes toil for 36 hours straight. Advocates for the 80-hour week have said that residents have fallen asleep while performing surgery or while driving home after their shifts.

CNN
SHOW: AMERICAN MORNING WITH PAULA ZAHN 07:00
June 19, 2002 Wednesday
Doctor Comes Up With Way to Try to Prevent Hospital Mistakes
DARYN KAGAN, CNN ANCHOR: We've all heard the horror stories: hospital patients who died or lost limbs because of medical mistakes. A report in 1999 showed that hospital mistakes killed 44,000-98,000 patients a year. But since then, one doctor has come up with a way to try to prevent those mistakes.

Portland Press Herald (Maine)
June 19, 2002 Wednesday, Final Edition
Moves pending to require more time off for residents; Now, hospital patients can be treated by a physician who's been on duty for more than 100 hours.
Patients hospitalized for injury or illness may soon benefit from several national initiatives attempting to assure that the medical residents who help care for them are actually awake when they do so.
Residents, who are doctors who have completed medical school and are being trained in hospitals, now can work from 100 to 120 hours a week.

The New York Times
June 18, 2002, Tuesday, Late Edition - Final
Oops, Wrong Patient: Journal Takes On Medical Mistakes
The patient had been on the operating table for an hour. Doctors had made an incision in her groin, punctured an artery, threaded in a tube and snaked it up into her heart. Now they were stimulating her heart electrically, to test for abnormal rhythms.
The phone rang: it was a doctor from another department. What, he asked, were they doing with his patient? There was nothing wrong with her heart.

Press Association
June 18, 2002, Tuesday
'NHS ERRORS STUDY WAS FLAWED' - MEDICAL CHIEF
A new pilot study into NHS medical errors was so dogged by computer problems and poor incident logging that its findings are unreliable, it was claimed today.
The National Patient Safety Agency (NPSA) study recorded 27,110 "adverse incidents" in 28 trusts within nine months.
This suggests there could be around 970,000 such errors made each year within the NHS.
But the NPSA and Chief Medical Officer Professor Sir Liam Donaldson were forced to concede there were problems with the quality of the data.

National Underwriter, Property & Casualty/Risk & Benefits Management Edition
June 17, 2002
Medical Liability Shield Proposed
Health insurers and risk managers are applauding legislation aimed at encouraging the reporting of medical errors by easing fears of litigation.
S. 2590 would provide legal protection for information on medical errors reported voluntarily for the purposes of quality improvement and patient safety.

Employee Benefit News
June 15, 2002
Coalitions lead charge on patient safety
BYLINE: Kelley M. Blassingame
Many business health coalitions have made patient safety issues a top priority for years. So most were more than ready to spring into action after a 1999 report from the Institute of Medicine showed that between 44,000 and 98,000 preventable deaths occur annually because of medical error, and called providers to action to improve the quality of patient safety.
Today, the coalitions have emerged as a focal point for activity and recommendations advanced through the private sector.
In 2001, the Leapfrog Group - comprised of more than 100 Fortune 500 companies and other large employers - launched its three-pronged approach to boosting patient safety and reducing fatal medical errors. Health coalitions, among them the National Business Coalition on Health (NBCH), felt they'd finally found a way to demonstrate their sound commitment to safety and saving lives.

The Times Union (Albany, NY)
June 14, 2002 Friday THREE STAR EDITION
Giving doctors a rest; A national group follows New York's lead in placing limits on residents' work weeks
It's been 13 years since New York became the first state in the nation to limit the number of hours worked by new doctors assigned to hospital residency. Now, at long last, this welcome reform will soon be the national norm, ending a long -- and in the eyes of many, dangerous -- tradition of working young doctors for as long as 120 hours a week.
New York's limits were imposed in the aftermath of two highly publicized cases involving overtired doctors who made mistakes that proved fatal to their patients. The most celebrated case occurred in 1984, when 18-year-old Libby Zion, daughter of writer Sidney Zion, died at New York Hospital-Cornell Medical Center. The two residents treating her were accused of failing to find out enough about the medicine she was taking and failing to properly monitor her vital signs. A year later, two residents at Albany Medical Center Hospital injected an anti-cancer drug into the spine of 21-year-old Lillian Cedeno that should have been administered intravenously. She died three months later. Her daughter, who had been delivered by Caesarean section at the hospital, lived for only 25 days.

The New York Times
June 13, 2002, Thursday, Late Edition - Final
Hospital Accreditor Will Strictly Limit Hours of Residents
In a move that is expected to make a significant change in the way doctors are trained, the group that accredits the nation's teaching hospitals said yesterday that it would impose strict new limits on the number of hours worked by medical residents.
The rules, intended to reduce the risk of dangerous errors by sleep-deprived young doctors, are to take effect in July 2003. They will limit the workweek to 80 hours, require at least 10 hours of rest between shifts, restrict duty to no more than 24 hours at a time and restrict work outside the hospital.

Indianapolis Business Journal
June 10, 2002 Safer medical devices could boost local company; Firm makes key part for asmart' pumps
A California medical-device manufacturer's efforts to tackle one of health care's toughest challenges a medication errors may pay off for an Indiana firm.
Lebanon-based Etalon has worked with San-Diego-based Alaris Medical Inc. to update a key component it makes for Alaris' intravenous infusion pump. Alaris and Etalon have redesigned the pump to allow it to read data and stop medicine flowing through the IV lines if a problem is detected.
Etalon, a division of Piezo Technologies in Park 100, has been manufacturing its componentaa transducer it designed that senses how much air is in an IV lineafor the popular earlier-version Alaris pump for 15 years.

Medicine & Health
June 10, 2002
'Tripartisan' group unveils patient safety bill; Medical Errors.
At a June 5 press conference, a "tripartisan" Senate group unveiled a bill designed to encourage medical professionals to voluntarily report medical errors, near-misses, and related information to "patient safety organizations" by shielding such reports from use in litigation and other forums. The Patient Safety and Quality Improvement Act is sponsored by Sens. Jim Jeffords (I-VT), John Breaux (D-LA), Bill Frist (R-TN), and Judd Gregg (R-NH).
Patient safety organizations would be private groups that, according to an explanation of the bill circulated by its sponsors, are "intended to act as 'change agents,' to ensure that data is collected, analyzed, and utilized to improve the health care delivery system." To qualify as a PSO, an organization "must certify that it is able to collect and analyze patient safety data, develop and disseminate information related to such data ... provide direct feedback and assistance, and provide appropriate confidentiality and security."

Knoxville News-Sentinel (Tennessee)
June 9, 2002, Sunday
Sen. Frist's medical error bill unlikely to pass
Hospitals, insurance companies and physicians have been working many years to end tragic medical errors where the wrong kidney is removed or the wrong prescription is filled, but errors keep occurring.
The U.S. Senate's only physician, Bill Frist, R-Tenn., says it is time to pass federal legislation to set up a national system where doctors and nurses can voluntarily report errors to an internal panel designed to figure out ways to avoid their repetition. The panel would promise to keep the names confidential when sharing error information with other hospitals to check for patterns and the best solutions.
Frist was among three senators last week who introduced the bill.

The Daily News Leader (Staunton, VA)
June 3, 2002 Monday
Our View
'Black boxes' may prevent medical error
"Black boxes," those ominously-named recorders that have become inextricably associated with the final tragic moments of an airliner and its passengers and crew, may find a more benevolent and hopeful incarnation in hospital operating rooms, if University of Virginia researchers have their way.
The university has spent $40,000 and several months in developing its new system, which involves videotape and recording devices that document what goes on during procedures performed at the U.Va.

AORN Journal
June 1, 2002
Formula for success with safety--just do it! Editorial.
Tackling change is difficult. Tackling a national safety initiative that should influence patient care in every perioperative setting across the nation is huge. Though this is a massive undertaking for perioperative nurses, it is an even bigger mission for the nonbelievers, noncompliers, and nonsupporters who never seem willing to "go with the program" when the nursing industry makes changes to sustain safe practices.
FLIGHT, FIGHT, OR GO WITH THE PROGRAM
For some people going with the program never seems to be an option. The first responses most humans experience during times of stress are flight or fight. Rather than assume that decisions are implemented for the fight reasons, some people choose the stress response. The cartoon character Dilbert explains human behavior by saying, "Nothing defines humans better than their willingness to do irrational things in pursuit of phenomenally unlikely payoffs." (1) The payoffs for challenging practices that are believed to improve patient care are difficult to understand, but human nature often overcomes common sense. The result is difficulty implementing some of the simplest practices. Many of you probably can relate to stories about nonbelievers, noncompliers, and nonsupporters in your settings and have seen the flight or fight responses influence outcomes in unexpected ways.

Consumers' Research Magazine
June 1, 2002
Connecticut will require hospitals and outpatient surgical centers to begin reporting to the state health department all medical errors that kill, seriously injure, or endanger patients; Consumer Notes ...; Brief Article
Connecticut will require hospitals and outpatient surgical centers to begin reporting to the state health department all medical errors that kill, seriously injure, or endanger patients. The new law, which takes effect in October, was passed after recent reports in the Hartford Courant linked 4,400 deaths in Connecticut in the past decade to medical errors.

Journal of Southeast Asian Studies
June 1, 2002
British policy discussions on the opium question in the Federated Shan States, 1937-1948.
British rule in Burma has been examined at many levels; however, the opium policy applied in the indirectly ruled Shan States has not received the same degree of examination. The Federated Shan States formally came into existence as of 1 October 1922 as a backward tract under the authority of the Governor of Burma. Control over the production and distribution of opium in the trans-Salween region of the States became an important issue when Burma was separated from India in 1937, as it involved a number of complex issues at the local, imperial and international levels. It is the purpose of this paper to provide an analysis of British policy towards the production and distribution of opium in the Federated Shan States from 1937 until Burma's independence in 1948.

Modern Physician
June 1, 2002, Saturday
Quality pioneers: A Milwaukee hospital is among the first to adapt a stringent industrial model to healthcare; Six sigma solution
Until recently, patients at Froedtert Memorial Lutheran Hospital in Milwaukee sometimes endured repetitive lab tests. Specimen carriers placed in a pneumatic delivery system mysteriously disappeared en route from the collection sites to the lab, resulting in finger-pointing between Froedtert's lab technicians and nurses.
Now, medical directors at the 413-bed, not-for-profit teaching hospital say they have cracked the case of the missing tube carriers using six sigma analysis. Six sigma team members broke down the delivery process and investigated each step for possible errors. It led them to discover a hole in the pneumatic pipe above the ceiling near the lab where eight lost delivery carriers had fallen.
''We're very happy with six sigma because it represents a methodology that we think has applicability to the healthcare environment,'' says Andrew Norton, M.D., Froedtert's CMO and a member of the hospital's six sigma steering committee. ''In our experience, it adds discipline and metrics, which have historically been lacking in traditional medical-error reduction.''

Modern Physician
June 1, 2002, Saturday
Dead tired
On Oct. 10, 1993, Daphne Izer's 17-year-old son, Jeff, his girlfriend and three other high- schoolers were in a car run over by a semitrailer truck whose driver had fallen asleep. Four of the teens were killed, including Jeff.
Angered, Izer and her husband formed Parents Against Tired Truckers, based in their hometown of Lisbon Falls, Me. Izer also has testified before Congress, focusing on a 1938 exemption in the Fair Labor Standards Act that virtually mandates bone-tired truckers to roll 80,000-pound cannonballs down the roads.

Stanford Law Review
June 1, 2002
Reconciling experimental incoherence with real-world coherence in punitive damages.
Few complaints about a legal system resonate louder than charges of incoherence. (1) A system that fails to treat similarly situated parties equally cannot be squared with fundamental notions of fairness and justice. (2) Incoherence unintentionally converts law into a lottery. Even charges of bias are less pernicious in some ways, because the targets of bias can organize and voice their opposition. Incoherence has no constituency and yet also no organized opposition.
Recent psychological research findings of incoherence pose a dilemma for law. Cognitive psychologists suggest that human judgment is, by nature, incoherent. (3) Judgments made in an individual case often do not comport with judgments made in the aggregate. In particular, Predictably Incoherent Judgments ("PIJ") provides convincing experimental evidence that people lack the basic cognitive skills necessary to translate qualitative moral judgments into quantitative numeric scales. (4) To the extent that a legal system relies on individuals to accomplish such translations, it risks incorporating incoherence into its judgments.

The Virginian-Pilot(Norfolk, Va.)
May 30, 2002 Thursday Final Edition
HEALTH WORKERS AIM TO PROTECT PATIENTS FROM MEDICAL ERRORS
When Dr. Carl Armstrong was working as a resident, shame kept him from telling anyone about a serious medical mistake.
He prescribed aspirin for a man taking blood-thinning medication - even though a nurse's note should have warned him about a potentially dangerous drug interaction. When the patient later confronted him with his mistake, Armstrong said, his heart sank.
"I was embarrassed because I was the doctor and I was supposed to be teaching the patient, and here was the patient teaching me," Armstrong said Wednesday. "I didn't report it at the time. There was no way to learn from this and prevent other residents from making the same mistake."

Deseret News (Salt Lake City, Utah)
May 24, 2002, Friday
SECTION: WIRE; Pg. A01 Liability sparks shortage of OBs
Utahns are feeling the pinch of a nationwide shortage of obstetricians and other medical specialists. And it's not confined to rural areas.
The issue is medical liability, according to Mark Fotheringham, spokesman for the Utah Medical Association. Malpractice insurance premiums have shot up. Some insurers, including St. Paul Companies Inc., the second-largest malpractice insurer in the country, have stopped writing any medical liability insurance, saying they were hemorrhaging money. While the number of lawsuits hasn't risen much, the jury awards have.

Congressional Testimony
May 24, 2002 Friday
COMMITTEE: SENATE HEALTH, EDUCATION, LABOR AND PENSIONS PATIENT SAFETY: WHAT IS THE ROLE FOR CONGRESS?
Statement of Tommy G. Thompson Secretary of Health and Human Services Senate Health, Education, Labor and Pensions Patient Safety: What is the Role for Congress? Thursday, May 24, 2001 Good morning, Mr. Chairman and members of the Committee. I am honored to appear before you today to discuss the important issue of reducing medical errors and improving the safety of the health care services that Americans receive. I would like to commend you, Mr. Chairman, and your colleagues for the role that you have played in helping to focus attention on this issue and for your commitment to finding solutions to what is by any estimate one of the leading public health challenges that we face today. Your leadership in this area has constituted a vital service to the Nation and will be critical as we move forward in this endeavor. For the most part, the findings described in the Institute of Medicine's (IOM) landmark November 1999 report, To Err is Human: Building a Safer Health System, are no longer front-page news. But the findings are no less serious, and they present no less of a challenge for all of us who care deeply about the quality of our Nation's health care system and the lives of the people who are affected when mistakes occur. Another report released by the IOM in March 2001, Crossing the Quality Chasm: A New Health System for the 21st Century, has served as a reminder of what the 1999 errors report made clear.

Congressional Testimony
May 23, 2002 Thursday
COMMITTEE: HOUSE ENERGY AND COMMERCE ASSESSING AMERICA'S HEALTH RISKS: HOW WELL ARE MEDICARE'S CLINICAL PREVENTIVE BENEFITS SERVING AMERICA'S SENIORS? HOW WILL THE NEXT GENERATION OF PREVENTIVE TREATMENTS BE INCORPORATED AND PROMOTED IN THE HEALTH CARE SYSTEM?
Statement of Dr. David W. Fleming M.D. Acting Director Centers for Disease Control and Prevention House Energy and Commerce Subcommittee on Oversight and Investigations Assessing America's Health Risks: How Well Are Medicare's Clinical Preventive Benefits Serving America's Seniors? How Will the Next Generation of Preventive Treatments be Incorporated and Promoted in the Health Care System? May 23, 2002 Thank you, Mr. Chairman, and Members of the Committee, for the opportunity to speak to you today about an issue that is of critical and increasing importance at the Centers for Disease Control and Prevention (CDC), and indeed for the American people. We at CDC are pleased to join our federal and non-federal partners in addressing the challenges facing Medicare, and identifying opportunities to improve the health of older. Before talking more specifically about improving the health of older adults, I would like to provide some context. Chronic diseases account for nearly 75 percent of the deaths in this country, are the leading causes of disability and long-term care needs, and represent nearly 75 percent of all health-related costs. Although chronic diseases are not limited to older adults, these conditions, such as cardiovascular disease, cancer, diabetes, and arthritis are heavily concentrated in adults age 50 and over. Among the 10 leading causes of death, the top six are concentrated in older adults. Premature death and much of the illness and disability associated with these diseases is preventable, even among older adults.

Drug Topics
May 20, 2002
Hospitals are issued a call to arms on patient safety; Brief Article
The estimates are staggering: 44,000-98,000 patients die each year due to medical errors; 8.1 million households have been affected by a serious medical error; medical errors cost the healthcare system between $ 17 and $ 29 billion annually.
These disturbing numbers have been reported widely by the press for the past several years. Nevertheless, according to David Page of the National Patient Safety Foundation (NPSF), "there has not yet been an industrywide response, a high-profile statement to the public, to the people we serve."
With the launch of the Stand Up for Patient Safety Campaign in Indianapolis last month, NPSF took the first step in implementing such a response. Page considers the Stand Up for Patient Safety Campaign a "call to arms for the industry" in addressing the issue of patient safety.

The New York Times
May 12, 2002, Sunday, Late Edition - Final
Paid Notice: Deaths
MACGREGOR, FRANCES COOKE

MACGREGOR-Frances Cooke. With apologies for the delay to her friends and colleagues, it is with regret that we advise that Frances Cooke Macgregor, an expert on the psychological effects of facial deformities, died on Christmas Eve (2001) at her retirement home in Carmel, California. She was 95 and died of congestive heart failure. She was a renowned social scientist whose research and writing on the social and psychological significance of facial differences was the first acknowledgement of disfigurement as a disability. Her publications document 40 years of research. Mrs. Macgregor was born in Portland, Oregon, but grew up in San Rafael, California and earned a bachelor's degree in economics from the University of California at Berkeley in 1927.
Years before it was frontpage news in the New York Times (Sunday, December 19, 1999), she wanted her philanthropic funds to go to studying medical errors caused by physicians and other health professionals. On the same page as the continuation of The New York Times article of December 19, 1999, "Breaking Down Medicine's Culture of Silence", the Institute of Medicine estimated that between 44,000 and 98,000 Americans die each year as a result of medical errors. Macgregor had already contributed to studies by the Institute of Medicine and also the Harvard Medical School in her name through the aegis of The Commonwealth Fund. She has left her estate to The Commonwealth Fund who will administer the Frances Cooke Macgregor Awards for further study of iatrogenic illness.

Congressional Press Releases
May 8, 2002 Wednesday
TAUZIN STATEMENT ON REDUCING MEDICAL ERRORS
:Wednesday, May 8, 2002
Tauzin Statement On Reducing Medical Errors
WASHINGTON (May 8) -- House Energy and Commerce Committee Chairman Billy Tauzin (R-LA) is scheduled to deliver the following remarks today at a Health subcommittee hearing on reducing medical errors:
"Thank you, Mr. Chairman for holding this important hearing to discuss medical errors.
"Patient safety is, and should always be, an important concern for our committee. Government policies should always promote and encourage America's companies to produce products and services that reduce the incidents of consumer harm or error. This is not only sound public policy, but good business sense. Competition drives innovation, and it is this impetus that has made America the world leader in new solutions to help people live longer and better.

The Edmonton Sun
May 8, 2002 Wednesday, Final Edition
CANADIAN DOCS LAUNCH FATAL MISTAKES PROBE
Canada has launched a study to examine the extent of medical mistakes in hospitals that some experts say kill 10,000 people every year in this country.
Errors range from patients having the wrong part of their body operated on, being given incorrect medication or being misdiagnosed.
Medical mistakes are a worldwide problem and countries such as the United States, Australia, the United Kingdom, New Zealand and Denmark have studied the issue and created ways to reduce errors and save lives, said Dr. Ross Baker, who is leading the study at the University of Toronto.

The Record (Kitchener-Waterloo)
May 8, 2002 Wednesday Final Edition
Medical errors subject of study; Mistakes kill 10,000 Canadians a year, some experts say
Canada has launched a study to examine the extent of medical mistakes in hospitals that some experts say kill 10,000 people every year in this country.
Errors range from patients having the wrong part of their body operated on, being given incorrect medication or being misdiagnosed.
Medical mistakes are a worldwide problem and countries such as the United States, Australia, the United Kingdom, New Zealand and Denmark have studied the issue and created ways to reduce errors and save lives, said Dr. Ross Baker, who is leading the study at the University of Toronto.

Canadian Business and Current Affairs
Canadian Press Newswire
May 7, 2002
Canada launches study to examine extent of medical mistakes in hospitals
(Record in progress)
VANCOUVER (CP) _ Canada has launched a study to examine the extent of
medical mistakes in hospitals that some experts say kill 10,000 people
every year in this country.
Errors range from patients having the wrong part of their body operated on,
being given incorrect medication or being misdiagnosed.
Medical mistakes are a worldwide problem and countries such as the United
States, Australia, the United Kingdom, New Zealand and Denmark have
studied the issue and created ways to reduce errors and save lives, said
Dr. Ross Baker, who is leading the study at the University of Toronto.
So far, researchers have used information from other jurisdictions to
estimate that 10,000 Canadians die annually because of medical errors made
by health professionals.

Health Data Management
May, 2002
I.T. Helps Steer Caregivers from Danger of Medical Errors;
Organizations are using different information technologies to prevent errors of omission and other breakdowns in care delivery.
Millions of dollars and countless trees have been sacrificed in health care industry research to pinpoint the cause of preventable medical errors, which kill thousands of people in the United States every year.
For Neil Bard, M.D., lead physician at Richland Hospital, Richland Center, Wis., the explanation for many errors is simple: "People forget things," he says.
"Patients typically come in for episodic care. So a physician might be treating a patient for a head cold and not know or remember the patient has a heart condition, or needs to have a test done, because the information is not there in front of them," Bard explains. "The patient forgets to mention a condition to a physician, so the physician might treat the head cold and not treat a serious, underlying condition. And not treating that is an error of omission."

Knight Ridder/Tribune News Service
San Jose Mercury News
April 30, 2002, Tuesday
2 patients sue Stanford medical center
Two patients who underwent surgery at Stanford University Medical Center have sued the elite teaching hospital for leaving foreign objects _ either gauze or sponges _ inside their bodies after the procedures.
The lawsuits, filed in April within 10 days of each other in Santa Clara County Superior Court, highlight ongoing concern over medical errors in America's hospitals. The U.S. Centers for Disease Control and Prevention estimates that objects have been left inside as many as 15,000 people. And a recent Institute of Medicine report estimated that tens of thousands of patients die from medical errors every year.

Business Wire
April 26, 2002, Friday
AORN Announces Patient Safety Initiative; Los Angeles-based Sandel Medical Industries L.L.C. Exclusive Sponsor
The incidence of medical errors resulting in patient death is an issue of critical importance.
In its 1999 study entitled To Err is Human: Building a Safer Health System, the Institute of Medicine reported that 44,000 to 98,000 deaths occur annually as a result of medical errors, including medication errors, surgical mistakes, and surgical complications. According to the report, it is estimated that the total national cost for medic