Citations to IOM report


2003 Citations to the 1999 Institute of Medicine Report that 44,000 to 98,000 People Die Annually Due to Hospital Errors These are "leads" only - Contact publishers for full text.	http://md-jd.info http://md-jd.info/errors.htm

Health & Medicine Week
December 22, 2003
MEDICAL ERROR: Study finds physicians reluctant to acknowledge, deal with mistakes
Doctors participating in internal medicine hospital conferences designed to review adverse medical events do not often discuss related medical errors, according to a study led by researchers from the San Francisco VA Medical Center (SFVAMC).
Study results showed that participants in surgery conferences were more likely than those in internal medicine conferences to discuss medical errors as errors and to attribute errors to a particular cause. Conference leaders for both groups missed opportunities to use explicit language in error discussion, according to the researchers.
The study appeared in the December 3, 2003, issue of the Journal of the American Medical Association.
"The findings of the study point to a culture that has difficulty acknowledging and dealing with error," says the study's senior author, Seth Landefeld, MD, associate chief of staff for geriatrics at SFVAMC; professor and chief of geriatrics at University of California, San Francisco; and senior scholar in the Department of Veterans Affairs National Quality Scholars Program.

Managed Care Weekly Digest
December 22, 2003
MEDICAL ERROR: Study finds physicians reluctant to acknowledge, deal with mistakes
Doctors participating in internal medicine hospital conferences designed to review adverse medical events do not often discuss related medical errors, according to a study led by researchers from the San Francisco VA Medical Center (SFVAMC).
Study results showed that participants in surgery conferences were more likely than those in internal medicine conferences to discuss medical errors as errors and to attribute errors to a particular cause. Conference leaders for both groups missed opportunities to use explicit language in error discussion, according to the researchers.
The study appeared in the December 3, 2003, issue of the Journal of the American Medical Association.
"The findings of the study point to a culture that has difficulty acknowledging and dealing with error," says the study's senior author, Seth Landefeld, MD, associate chief of staff for geriatrics at SFVAMC; professor and chief of geriatrics at University of California, San Francisco; and senior scholar in the Department of Veterans Affairs National Quality Scholars Program.

The Baltimore Sun
December 15, 2003
Monday FINAL Edition Correction Appended
From tragedy, a quest for safer care; Cause: After medical mistakes led to her little girl's death, Sorrel King joined with Johns Hopkins in a campaign to spare other families such anguish.
Sorrel King seemed small up on stage next to the two photographs of her daughter Josie, projected on a huge screen. In one shot, the brown-haired girl looked like she'd been caught in mid-giggle.
Most of the speakers at this Washington conference on patient safety last March were professionals, armed with statistics and Powerpoint presentations. Sorrel arrived with a few sheets of paper filled with words written in pain. She wasn't there to share research or discuss hospital policies. She was there to talk about the loss of her child.
"I am not a doctor or a nurse, and am by no means an expert in this field," she began. "I am a mother who has seen the darkest side of a hospital."
Because of an editing error, an article in The Sun yesterday about medical errors gave the wrong title for Dr. Edward D. Miller. He is chief executive officer of Johns Hopkins Medicine and dean of the Johns Hopkins University School of Medicine.

The Baltimore Sun
December 14, 2003 Sunday FINAL Edition
How medical error took a little girl's life; Tragedy: After being scalded in a bathtub accident, 18-month-old Josie King was recovering at Johns Hopkins. Then something went terribly wrong.
During those frightening first days in the hospital, Sorrel King came to trust the doctors and nurses looking after her 18-month- old daughter. Hooked up to tubes and machines, sterile dressings covering her burns, Josie looked nothing like the little girl who danced through life wearing ladybug shoes and a gap-toothed grin.
The medical team at the Johns Hopkins Children's Center constantly monitored Josie's mixture of drugs, watched for signs of infection, performed skin grafts to repair the damage from her bathtub accident. If she fussed, someone would immediately check whether she was in pain. After she struggled to fill her lungs with air, a ventilator regulated her every breath. Sorrel, keeping vigil in the intensive-care unit, allowed herself to feel relief at seeing her daughter slowly heal.
As the long days settled into a routine, Sorrel began to view the doctors and nurses not just as caregivers in white coats and scrubs but as people like her, with vibrant lives waiting outside the hospital. The attending physician was Greek and loved to cook. The critical-care doctor was a new father. The pretty pediatric surgeon, a prodigy who had graduated from medical school at age 19, had a long-distance romance. Sorrel thanked them with brownies and fruit baskets and her admiration.

PR Newswire
December 9, 2003, Tuesday
Cardinal Health Introduces Medical Gloves That Help Improve Skin, Relieve Dermatitis; New Gloves Help Protect Hands From Skin Problems That Increase Infection Risks for Health Workers and Patients
Cardinal Health (NYSE: CAH), the leading provider of products and services supporting the health-care industry, announced today it has received clearance from the U.S. Food and Drug Administration to market an advanced new line of medical gloves made with Neu-Thera(TM), an emollient that is proven clinically to improve skin health and protect hands from irritation. The gloves are the first to be manufactured with a proprietary formula that protects, restores, moisturizes and soothes hands. Repeated washing, scrubbing and gloving by physicians and nurses can cause dry and irritated hands. The U.S. Centers for Disease Control and Prevention recommends that health-care workers select products containing emollients to lower the risk of irritant contact dermatitis (Guideline for Hand Hygiene in Healthcare Settings, October 2002.) Skin irritation, according to the CDC, is one reason clinicians don't adhere to recommended hand hygiene guidelines. Contact dermatitis is a painful condition characterized by dry, itchy, red and cracked skin. Dermatitis can increase the risk of infection for patients and health-care workers. According to the U.S. Bureau of Labor Statistics, nurses miss an average of two work days annually due to dermatitis. Following more than two years of research, development and clinical testing, Cardinal Health is introducing the Neu-Thera formulation in its leading line of Esteem(TM) synthetic exam and surgical gloves. Esteem surgical gloves are made of polyisoprene, which is known for its strength and barrier properties, elasticity and softness. Esteem exam gloves are made from nitrile, which is known for its chemical resistance, barrier integrity, elasticity and strength.

United Press International
December 5, 2003 Friday

Internal medicine docs review cases poorly
Internal medicine doctors' review of bad outcomes often do not include discussion of related medical errors, California researchers said Friday.
The San Francisco VA Medical Center study revealed internal medicine hospital conferences designed to review adverse medical events do not often discuss doctors' mistakes.

United Press International
December 5, 2003 Friday
Health and Science News
Poliovirus used to create anti-cancer drug
DURHAM, N.C., Dec. 5 (UPI) -- North Carolina researchers used the anti-cancer properties of poliovirus to create a virus that kills cancer cells, Duke University reported Friday.
The new virus killed cancer cells in laboratory cell cultures and in animals -- and without causing polio, said Matthias Gromeier, assistant professor of molecular genetics and microbiology at the Duke Comprehensive Cancer Center.
Testing of the new viral agent in humans should begin within two years, he said.
In the study, the modified poliovirus killed cancer cells derived from primary brain tumors as well as cells derived from breast and colon cancer metastases in four to six hours.

The Oprah Winfrey Show
December 3, 2003 Wednesday
Outrageous medical mistakes; guests discuss what has happened while under the care of a doctor that has affected their lives
OPRAH WINFREY: What you need to know before you go to any doctor. He woke up from surgery without his penis.
Can you believe this story?
For four days, doctors refused to deliver these twins.
Mr. GARY SUSSER: The only thing I could have done was pick up a knife myself to deliver these babies.

Patient Care
December 1, 2003
Reducing medical errors in primary care: medical errors come in all shapes and sizes and stem from a variety of causes. Many can be avoided by vigilance and common sense; Enhancing Your Practice
According to the 1999 Institute of Medicine (IOM) report To Err is Human: Building a Safer Health System, 44,000 to 98,000 Americans die each year as a result of medical errors. (1) The exact numbers are debated, but the message is clear: Medical professionals must find ways to decrease the incidence of medical mistakes. The IOM estimates are based solely on inpatient errors, and most medical error research has been performed in hospital settings. The majority of medical care, however, is provided in the ambulatory arena, with nearly 907 million outpatient visits in 2000. The study of ambulatory medical errors is in its infancy, and it may be years before research guides us to the best means of reducing errors in this setting. Fortunately, many of the medical errors that occur in the ambulatory setting can be eliminated with the application of a few common-sense strategies.
A PRIMER ON MEDICAL ERRORS
The IOM describes 2 types of errors: failure to complete a planned action as intended (error of execution) and use of an erroneous plan to achieve a medical outcome (error of planning).

Fortune
November 24, 2003
IT Takes On The ER (Results May Vary); Hospitals, worried about streamlining and safety, are finally joining the digital revolution. But cautious doctors and entrenched bureaucracies are causing tech firms chronic pain.
It's midmorning in late October, and Maimonides Medical Center in Brooklyn is already frenetic. On the fifth floor Dr. Victor Guadagnino, a private-practice physician, checks lab reports at a computer terminal for an 82-year-old patient with congestive heart failure admitted the day before. He clicks through screen after screen: Her echocardiogram shows decreased function, her thyroid is out of whack, and her kidneys are abnormal. He can see that an ultrasound on her liver has been scheduled for this morning. No need to reorder. He shakes his head about her prognosis. "This is going to be a problem," he says before heading off to her room to check her in person.
One floor up Dr. Andrew Yacht orders treatment for a pneumonia patient. Before he can key in his request, a prompt appears. "Is this the correct patient?" He clicks yes. Another screen pops up: "The accepted antibiotic is Gatifloxacin." Before he can order it, the computer indicates that he should take two sets of blood cultures and a sputum study, and asks whether the patient is on a given list of antiarrhythmics. If so, the program warns, Gatifloxacin should not be administered because of the risk of heart toxicity.

Newsbytes
November 21, 2003, Friday
Doctors Advised to Keep Records Electronically
The Institute of Medicine yesterday called for hospitals and physicians to adopt electronic record-keeping systems that would prevent tens of thousands of fatal medical errors a year and form the basis for a nationwide flow of patient information among practitioners and medical facilities.
The government would set the standards for electronic records and error-surveillance systems but would not tell hospitals and clinics what to buy.
Use of such systems, which can guide treatment decisions as well as catch mistakes, would be voluntary, said the institute, which advises the federal government on medical policy. Over time, however, electronic record-keeping and participation in a national information network should become conditions for participating in programs such as Medicare, making them essentially mandatory.

Technews.com
November 21, 2003
FT-ACC-NO: A20031121EE-6698-GNW
DOCTORS ADVISED TO KEEP RECORDS ELECTRONICALLY
The Institute of Medicine yesterday called for hospitals and physicians to adopt electronic record-keeping systems that would prevent tens of thousands of fatal medical errors a year and form the basis for a nationwide flow of patient information among practitioners and medical facilities.
The government would set the standards for electronic records and error-surveillance systems but would not tell hospitals and clinics what to buy.
Use of such systems, which can guide treatment decisions as well as catch mistakes, would be voluntary, said the institute, which advises the federal government on medical policy. Over time, however, electronic record-keeping and participation in a national information network should become conditions for participating in programs such as Medicare, making them essentially mandatory.

The Washington Post
November 21, 2003 Friday Final Edition
Doctors Advised to Keep Records Electronically; Technology Could Prevent Errors, Report Says
The Institute of Medicine yesterday called for hospitals and physicians to adopt electronic record-keeping systems that would prevent tens of thousands of fatal medical errors a year and form the basis for a nationwide flow of patient information among practitioners and medical facilities.
The government would set the standards for electronic records and error-surveillance systems but would not tell hospitals and clinics what to buy.
Use of such systems, which can guide treatment decisions as well as catch mistakes, would be voluntary, said the institute, which advises the federal government on medical policy. Over time, however, electronic record-keeping and participation in a national information network should become conditions for participating in programs such as Medicare, making them essentially mandatory.

MarketWatch
November 19, 2003 Wednesday
Doctors next in ratings initiatives
Second of two parts. See Part 1:
SAN FRANCISCO (CBS.MW) -- Before Todd Gordon's son was born a year ago, he and his wife turned to their health plan's Web site to find a pediatrician.
"As new parents freaking out about everything, we wanted to make sure we had the right pediatrician, or at least one we could relate to," says Gordon, 36.
Fortunately, they had few criteria: They wanted a doctor who lived close and was affiliated with a local Chicago hospital on their Destiny Health plan, a list that Destiny provided them. Ultimately, the Gordons landed on a hospital Web site where they compared pediatricians' bios before making their choice.

Congressional Testimony
November 19, 2003 Wednesday
COMMITTEE: HOUSE VETERANS AFFAIRS
MEDICAL RECORDS SHARING
Statement of Kem Clawson Director, Advanced Technology Solutions EMC Corporation
Committee on House Veterans Affairs Subcommittee on Oversight and Investigations
November 19, 2003
Chairman Buyer, Congresswoman Hooley, and distinguished members of the Oversight and Investigations Subcommittee, I am Kem Clawson, Director of Advanced Technology Solutions at EMC. It is an honor and pleasure to be here this morning.
EMC is the world leader in enterprise information storage systems, software, networks and services. Our company is focused exclusively on delivering solutions that enable organizations of all sizes to better and more cost-effectively manage, protect, share, and store information. Every dollar we invest, every engineer we employ, is focused on information storage. With revenues of over $5 billion in 2002, EMC has developed storage solutions for the majority of the world's largest banks, financial institutions, airlines, telecommunication companies, transportation companies, Internet Service Providers, educational institutions, and Federal government agencies.

Anchorage Daily News (Alaska)
November 18, 2003 Tuesday, FINAL EDITION
Error Relief; Hospitals use new technology to reduce potentially deadly medication and testing mistakes
Mistakes made in hospitals cause more deaths nationwide than car accidents, breast cancer or AIDS. Alaska's hospital officials read staggering statements like that in a 1999 national report by the private Institute of Medicine. The report drew from two large studies, one of Utah and Colorado hospitals and one of New York hospitals, and extrapolated the error rates over total U.S. hospital admissions in 1997. The institute estimated that errors killed 44,000 to 98,000 people every year and cost $17 billion to $29 billion in lost income and household productivity, and disability and health care costs
"That got everyone's attention," said Jim Moran, Providence Alaska Medical Center's pharmacy director. "It really was an eye-opener. Those numbers were scary."
The state's hospitals have responded with changes to reduce errors: Alaska Regional Hospital is bar-coding patients. Alaska Native Medical Center is filling prescriptions with robot technology. Providence is eliminating the human touch in its laboratory.

The Idaho Statesman
November 15, 2003 Saturday
Boise gets a taste of brewing national debate on health care; Gingrich shares his vision at a local conference
Gregory Hahn - Staff
There's a battle brewing over health care in America, and if you listen closely you can hear some of the artillery being fired right here in Boise.
In the past month, Boiseans have been able to hear from two of the people who may lead their sides into this fight. The state of Idaho could find itself in the forefront of the debates on long-term care, covering the uninsured, and other emerging questions.
"This is the right topic," said Gov. Dirk Kempthorne, who has place the issue on the national stage as head of the National Governors Association . "This is the right time. We need to find solutions."

Milwaukee Journal Sentinel
November 12, 2003 Wednesday FINAL EDITION
Many chances for mistakes in hospitals ; TAKES FIVE; LUCIAN LEAPE; Many chances for mistakes in hospital s
In 1999, the Institute of Medicine concluded that 44,000 to 98,000 people die each year from preventable medical errors. Lucian Leape was a part of that panel and says that the design of the hospital system -- not the staff -- makes it easy for errors to occur. A former pediatric surgeon, Leape has been a longtime advocate for a national computerized bar code system to help prevent dosing and prescribing errors. He also says hospitals should focus not on punishing people for their errors but on redesigning their systems to optimize patient safety and care. Leape is in town today and Thursday to talk to health care workers about creating a safe environment for patients. Leape, now an adjunct professor of health policy in the department of health policy and management at Harvard School of Public Health, spoke with medical reporter Kawanza L. Griffin from his office earlier this week.

United Press International
November 12, 2003 Wednesday
Patient information going digital
An organization representing family doctors said Wednesday it is forming an alliance with 10 technology companies to bring electronic health record technology to thousands of small-to-medium-sized medical practices that are struggling to afford digital upgrades.
The American Academy of Family Physicians said although many doctors' offices across the country already are using new computerized health record bookkeeping systems, many more do not. If the technology could be extended to the entire physician population, however, e-health records ultimately could save the nation billions of dollars -- though experts said there are no current savings estimates and it could take years to reap financial benefits.
Nationally, "administration inefficiencies can run as high as $300 billion," said Dr. Mark Leavitt, vice president of clinical initiatives for GE Medical Systems Information Technologies in Milwaukee, one of the companies participating in the alliance. Using electronic health records could cut those costs significantly, he added.

American College of Healthcare Executives Journal of Healthcare Management
November 1, 2003
Integrating Six Sigma with total quality management: a case example for measuring medication errors.
EXECUTIVE SUMMARY
Six Sigma is a new management philosophy that seeks a nonexistent error rate. It is ripe for healthcare because many healthcare processes require a near-zero tolerance for mistakes. For most organizations, establishing a Six Sigma program requires significant resources and produces considerable stress. However, in healthcare, management can piggyback Six Sigma onto current total quality management (TQM) efforts so that minimal disruption occurs in the organization. Six Sigma is an extension of the Failure Mode and Effects Analysis that is required by ICAHO; it can easily be integrated into existing quality management efforts. Integrating Six Sigma into the existing TQM program facilitates process improvement through detailed data analysis. A drilled-down approach to root-cause analysis greatly enhances the existing TQM approach. Using the Six Sigma metrics, internal project comparisons facilitate resource allocation while external project comparisons allow for benchmarking. Thus, the application of Six Sigma makes TQM efforts more successful.
This article presents a framework for including Six Sigma in an organization 's TQM plan while providing a concrete example using medication errors. Using the process defined in this article, healthcare executives can integrate Six Sigma into all of their TQM projects.

Pittsburgh Post-Gazette
October 28, 2003 Tuesday SOONER EDITION
New Test Combination Detects down Syndrome Earlier in Fetuses
A new combination of blood tests and ultrasound can detect fetuses with Down syndrome sooner and more accurately than standard U.S. screening tests, offering mothers-to-be more peace of mind and more time to decide whether to end a pregnancy.
The study of 8,216 women at a dozen U.S. medical centers confirms findings in England and elsewhere, where the combination is already widely used.
The usual blood screenings done in this country identify up to 75 percent of Down syndrome babies, but do not yield results until about 20 weeks into pregnancy, when abortion is more dangerous and often difficult to obtain.
The new combination -- two blood tests, ultrasound and the mother's age -- correctly identified 85 percent of fetuses with Down syndrome and yielded results at about 12 weeks.

Business Wire
October 27, 2003 Monday
Acupath Laboratories Says Make No Mistake, Medical Errors Are a Serious Reality; Tips for Reducing the Chance of Becoming a Medical Error Victim
Medical errors are a reality. It is estimated that medical errors are one of the Nation's leading causes of death. The Institute of Medicine estimates that as many as 44,000 to 98,000 people die in US hospitals as a result of medical errors. This means that more people die from medical errors than from car accidents, breast cancer or AIDS.

The Olympian (Olympia, WA)
October 22, 2003 Wednesday
Prescription medication stamped with new codes
Scanning technology will improve accuracy
BY SHARON MICHAEL
THE OLYMPIAN
Capital Medical Center nursing staff and patients still are getting used to the hardware and electronic beeps that accompany the bedside administration of medications.
Nurse Jennifer Wohld pushed a cart with a laptop computer into Phyllis Jefferson's room last week and scanned Jefferson's wristband and the prescribed medication before administering it to the Tumwater woman.
The new bar-code system uses technology found in grocery and department stores to ensure that the right patient is getting the prescribed medication in the correct amount at the right time.

Pittsburgh Post-Gazette
October 17, 2003 Friday SOONER EDITION
Learn from These Errors
Unfortunately too many physicians have adopted the mind-set that errors are shameful events, committed only by inferior doctors. Far too many medical errors go unreported, making it impossible for other doctors and hospitals to learn from them.

Modern Healthcare
October 13, 2003, Monday
Counting the risks; Study details costs of injuries during hospitalization
Although injuries during hospitalization are recognized as a major hazard in the healthcare system, little is known about their effective prevention. A new study released last week by the Agency for Healthcare Research and Quality lends more credence to some common-sense conclusions others previously had drawn about the problem.
The study, which appeared in the Oct. 8 Journal of the American Medical Association, estimated that medical injuries resulted in an estimated 32,591 patient deaths, $4.6 billion in additional national healthcare costs and 2.4 million extra days of hospitalization in 2000. It follows the landmark report in 1999 by the Institute of Medicine that concluded medical injuries account for 44,000 to 98,000 patient deaths and $17 billion in direct healthcare costs annually.

American Health Line
October 8, 2003 Wednesday
Medical Injuries: Led to 32,600 Deaths, $9.3b Cost in 2000
Medical injuries in U.S. hospitals in 2000 led to about 32,600 deaths, at least 2.4 million extra days of patient hospitalization and additional costs of up to $9.3 billion, according to a study published Tuesday in the Journal of the American Medical Association, the Wall Street Journal reports (Burton, Wall Street Journal, 10/8). Study authors Dr. Chunliu Zhan of the Agency for Healthcare Research and Quality and Dr. Marlene Miller of the Johns Hopkins Children's Center and colleagues analyzed records from 994 hospitals in 28 states, a sample representative of about 20% of U.S. hospitals (Fackelmann, USA Today, 10/8). Researchers considered 18 diagnostic billing codes previously found to be indicative of medical injuries, the Baltimore Sun reports. Those included accidental punctures, medical objects accidentally left in patients during surgery and sepsis infections (Bell, Baltimore Sun, 10/8). Because the analysis was based on billing data, researchers did not track some errors, such as adverse drug reactions (Wall Street Journal, 10/8). The study found that sepsis infections -- the "most serious complication" -- occurred in 2,592 patients, resulting in a 22% higher risk of death, $57,727 in additional costs and 11 extra days of hospitalization per patient, the AP/Detroit Free Press reports. Surgical wounds represented the second-most serious medical injury, with a nearly 10% higher risk of death, $40,323 in additional costs and nine extra days of hospitalization per patient (Tanner, AP/Detroit Free Press, 10/8). The authors concluded that medical injuries in hospitals "pose a significant threat to patients and incur substantial costs to society" and "are a serious epidemic confronting our health care system."

Deseret News (Salt Lake City, Utah)
October 8, 2003, Wednesday
Preventable complications cost more than $9 billion
CHICAGO -- Postoperative infections, surgical wounds accidentally opening and other often-preventable complications lead to more than 32,000 U.S. hospital deaths and more than $9 billion in extra costs annually, a report suggests.
Researchers from the U.S. government's Agency for Healthcare Research analyzed data on 18 complications sometimes caused by medical errors. They found that such complications contribute to 2.4 million extra days in the hospital each year.

Newsday (New York)
October 8, 2003 Wednesday NASSAU AND SUFFOLKEDITION
Medical Complications Prove Costly
Chicago - Postoperative infections, surgical wounds accidentally opening and other often-preventable complications lead to more than 32,000 U.S. hospital deaths and more than $9 billion in extra costs annually, a report suggests.
Researchers from the government's Agency for Healthcare Research and Quality analyzed data on 18 complications sometimes caused by medical errors.

St. Petersburg Times
October 8, 2003 Wednesday 0 South Pinellas Edition
Survey: Complications deadly, costly
Postoperative infections, surgical wounds accidentally opening and other often-preventable complications lead to more than 32,000 U.S. hospital deaths and more than $9-billion in extra costs annually, a report suggests.
Researchers from the U.S. government's Agency for Healthcare Research analyzed data on 18 complications sometimes caused by medical errors. They found that such complications contribute to 2.4-million extra days in the hospital each year.

The Oprah Winfrey Show (4:00 PM ET) - BNO
October 3, 2003 Friday
Outrageous medical mistakes; guests discuss what has happened while under the care of a doctor that has affected their lives
HOST: Oprah Winfrey
Executive Producer: Ellen Rakieten
Outrageous Medical Mistakes
Oprah Winfrey: What you need to know before you go to any doctor. He woke up from surgery without his penis.
Can you believe this story?
For four days, doctors refused to deliver these twins.
Mr. GARY SUSSER: The only thing I could have done was pick up a knife myself to deliver these babies.

PR Newswire
October 1, 2003, Wednesday
Department of Defense Awards Park City Solutions 'Concept Exploration Support' Contract for DoD Patient Safety Reporting System
Park City Solutions, the leading eHealth integration solution provider in healthcare, today announced the Department of Defense (DoD) has awarded Park City Solutions' Government Services Group the "Concept Exploration Support" contract for the DoD's Patient Safety Reporting System. (Logo: http://www.newscom.com/cgi-bin/prnh/20030609/PCSLOGO ) "This important phase of the patient safety system project analyzes the 'best of breed' patient safety applications both in the commercial sector as well as the Government, and provides the Department of Defense with the information necessary to acquire or develop a system," said Ed Rosas, Sr. Vice President, Park City Solutions. As many of us are aware, "First, do no harm" has been a cardinal rule of the medical profession for centuries. Yet any encounter with the healthcare system may result in unwanted and harmful consequences for the patient. These harmful outcomes have been called "preventable adverse events, iatrogenic injuries or simply medical errors." The magnitude of this problem and the extent of its impact were reported by the Institute of Medicine (IOM) in its report, "To Err is Human: Building a Safer Health System" (IOM 1999). "This report has influenced a number of initiatives with regards to recording and preventing medical errors", said Rosas. "The IOM report estimated that between 44,000 and 98,000 patients die every year because of medical errors -- a staggering number that captured the attention of the medical world, state and local governments, regulatory agencies, business leaders, and -- perhaps most importantly -- the public.

USA TODAY
October 1, 2003, Wednesday, FINAL EDITION
For many in U.S., good health care barely exists
: You have a heart attack. Your spouse gets you to a major teaching hospital in 15 minutes. Within another 30 minutes, doctors thread a tiny device into the clogged artery that caused the attack -- and reopen it (a procedure called angioplasty). You leave the hospital the next day with a handful of prescriptions and lifestyle advice that will sharply lower your risk of a second attack. You are back at work in a week.
After a heart attack in 1965, you would have been in the hospital a week or more and had a 28% chance of dying there. Today, that chance is only one in 10.

Business Wire
September 25, 2003 Thursday
Allscripts Wins Innovation Award at TETHIC 2003; TouchWorks EMR Selected as the Most Innovative Information Technology for Physician Practices
The Emerging Technologies & Healthcare Innovations Congress (TETHIC) selected Allscripts Healthcare Solutions (Nasdaq:MDRX) TouchWorks(TM) EMR as the "Most Innovative Information Technology in a Physician Community" at the 2003 TETHIE Awards on Tuesday night. The TETHIE Awards recognize industry leadership in the areas of innovation, technology, implementation, best practices, and research.
"TouchWorks is a unique application that leverages the best of today's technology to truly improve how patient care is delivered," commented Mark Anderson, Chief Executive Officer of AC Group, Inc. and Co-chairperson of the judging committee for the TETHIE Awards. "We found what this application can deliver in terms of patient safety to be particularly impressive."

The Indianapolis Star
September 8, 2003 Monday Final Edition
Change the system to safeguard NASA lives
Lisa Coffey's Sept. 5 column ("Columbia disaster report: Help hold NASA accountable") reports another example of "system failure" in American society, suggesting the public and our leaders don't know enough about the theory and practice of systems management needed to reduce if not avoid system errors.
NASA's errors cost seven lives.

Virginian-Pilot
September 3, 2003, Wednesday
Bar-Code Technology at Hampton, Va., Hospital Helps Prevent Overdoses
HAMPTON, Va.--Supermarkets have used bar-code scanners to monitor their merchandise for years. Now, nurses at the VA Medical Center in Hampton use similar technology to prevent overdoses.
Wielding a scanner that looks like a toy gun, registered nurse Dorothy Frazier matches bar codes printed on medicine bottles with those stamped on her patients' ID bracelets.
A computer confirms if Frazier is giving the right medication -- at the appropriate time and the correct dose.

The Virginian-Pilot
September 3, 2003 Wednesday Final Edition

Va Hospitals Set New Safety Bar; Technology to Protect Patients Serves as Model for Country
Supermarkets have used bar-code scanners to monitor their merchandise for years. Now, nurses at the VA Medical Center in Hampton use similar technology to prevent overdoses.
Wielding a scanner that looks like a toy gun, registered nurse Dorothy Frazier matches bar codes printed on medicine bottles with those stamped on her patients' ID bracelets.
A computer confirms if Frazier is giving the right medication - at the appropriate time and the correct dose.
If Frazier makes a mistake, a laptop computer on her medication cart flashes an alert.

Geriatric Times
September 1, 2003
Peer Review: Will More Statutes Make It Work?
Utilization Review Committees
When the Medicare law was enacted in 1965, it basically left quality issues up to hospitals and extended-care facilities (now known as skilled nursing facilities). The Medicare statute said that the hospital or extended-care facility had to establish a utilization review (UR) committee. This committee's principal function was to determine the appropriateness of admission to the facility, length of stay and quality of the professional services rendered. These statutes required the facility to govern itself relative to costs and quality.
It can be said that this peer review effort had negligible impact. During the Omnibus Budget Reconciliation Act of 1987 (OBRA 87) debate over regulations governing psychopharmacological medications, I learned why. One of the letters supporting the regulation was from a physician who wrote: "Gone are the days of the U.R. luncheon." He was referring to the practice in the 1960s and '70s when nursing home administrators would take a physician to lunch in exchange for his signature stating that a UR committee meeting had been conducted. This behavior did not exactly display the attitude that the U.S. Congress hoped for when it asked hospitals and nursing homes to govern themselves through a utilization review process.

Nursing Economics
September 1, 2003
Lessons from aviation: teamwork to improve patient safety; Patient Safety
Executive Summary
* Medical errors may contribute to as many as 44,000 to 98,000 deaths per year. * Effective teamwork may serve to avoid and manage error and also address increasing staff shortages, the growing need for cost reduction, and increasing patient expectations.
* The Institute of Medicine and others have encouraged health care providers to look to the aviation industry because of its long history of measuring and improving teamwork to prevent and mitigate errors.
MOST HEALTH CARE PROVIDERS now recognize that medical errors t are a significant problem. Errors are frequent, costly, and may lead to adverse events. Errors may contribute to as many as 44,000 (Thomas et al., 1999) to 98,000 (Leape, Lawthers, Brennan, & Johnson, 1993) deaths per year, according to estimates by the Institute of Medicine (IOM) (Kohn, Corrigan, & Donaldson, 1999). With prompting from groups such as the IOM, Joint Commission for Accreditation of Healthcare Organizations, The Leapfrog Group, The Agency for Healthcare Research and Quality, and others, providers are mobilizing to reduce errors and improve patient safety.

St. Cloud Times (St. Cloud, MN)
August 31, 2003 Sunday
System to track medical errors
State officials anticipate September launch for effort to boost hospitals' accountability
By Kate Kompas
kkompas@stcloudtimes.
A new system that regulates how the state will track medical errors at hospitals could start in September.
The system will empower the health department to make hospitals more accountable, said Mike Tripple, assistant director of hospital and nursing-home regulation for the state.
There isn't enough money yet to pay for the system, which will require hospitals to report 27 of the most-serious medical mistakes. They are known as the "never" incidents in hospitals, meaning they should never happen. National statistics show they too often do.

The Washington Post
August 31, 2003 Sunday Correction Appended Final Edition
It's Hard to Do No Harm When You've Had No Sleep
Most of us have some moment in our past when we went off the deep end and said or did exactly what we wanted, manners and consequences be damned. Some of us look back at this moment with satisfaction. Last week, after hearing the news that one of the nation's most famous hospitals had been cited for overworking its medical residents and in small ways making it difficult for them to do their job, I recalled my moment with a mixture of exhilaration and vindication.
It came in the spring of 1990. I was a second-year resident, splitting my time between the old (and now gone) Veterans Affairs hospital in Baltimore and the University of Maryland Hospital. I was working in the VA's "screening clinic," where patients with non-critical illnesses waited in large numbers to be seen. The clinic had nearly a dozen rooms, each with an examining table, desk, two chairs and, attached to the wall, a squeeze-bulb blood pressure cuff.
CORRECTION-DATE: September 05, 2003, Friday
CORRECTION:
An Aug. 31 Outlook article about the stresses of medical training incorrectly stated that about 100 people are accepted each year into the internal medicine residency at Johns Hopkins Hospital. The correct number is 36 people accepted out of more than 1,000 applicants. The total number of people in the three-year residency program ranges from 106 to 108.

Federal News Service
August 18, 2003 Monday
The Mclaughlin Group
Host: John Mclaughlin
Joined By: Tony Blankley, Patrick Buchanan, Susan Dentzer and Robert Laszewski
Taped: Thursday, July 31, 2003 Broadcast: Weekend of (Date)
Mr. Mclaughlin: Issue One: Prescription Relief.
President George W. Bush: (From videotape.) Economic security for America's seniors is threatened by the rising cost of prescription drugs. I'm pleased that both houses of Congress have responded by passing separate bills providing prescription drug coverage under Medicare. It's absolutely essential that the House and the Senate resolve their differences and enact a piece of legislation I can sign.
Mr. Mclaughlin: How best to add prescription drugs to Medicare is being sweated out by both chambers of Congress in a conference committee that reconvenes in the fall. It's proving to be a Herculean task on both the level of policy and complexity. This is an overhaul -- the biggest since Medicare's inception 38 years ago -- at a cost of $400 billion dollars over 10 years.
Federal News Service
August 14, 2003 Thursday
Remarks by Vermont Governor Howard Dean, Senator John Edwards (D-nc) and Senator Bob Graham (D-fl) at Iowa Health Care Forum
Moderator: Iowa Governor Tom Vilsack (D)
Location: Drake University, Desmoine, Iowa
GOV. VILSACK: Each of the last two speakers has indicated their background in medicine. I'm frank to say, all I've been is a patient and a payer. (Laughter.) Our next speaker to join us this afternoon is Governor Howard Dean from Vermont. (Applause.)
GOV. DEAN: Thank you. Tom told me that he almost introduced me as Governor Dean from Iowa. (Laughter.) And I've been here so often, I think I have a right to vote in the caucus, we're just trying to figure out which one. (Laughter.)
Let me say some thank yous before we start. Let me thank Tom Vilsack and his extraordinary staff for putting this together. This is a real service to the country, and we appreciate it. (Applause.) Let me thank all these incredible purple-and-yellow shirts who have been to every meeting I've been to in Iowa, anywhere I've been. And Andy Stern, the head of the SEIU is here and the SEIU for sponsoring this. Where is Andy? You're around somewhere. (Applause.) Let me thank AstraZeneca, who also is a cosponsor of this, and we'll try not to beat you up too bad. (Laughter.)

Courier-Post (Cherry Hill, NJ)
August 3, 2003 Sunday X Edition
Looking for a good hospital? Try asking a doctor
By ANGELA RUCKER
Courier-Post Staff
When you're trying to find a good hospital, the best person to ask for advice might be a good doctor.
"That's a huge factor in driving patients,' explained Dr. Charles Dennis, chairman of the Department of Cardiology at Deborah Heart and Lung Center in Browns Mills.
Advice from a doctor trumps the Internet, pamphlets and guides, and insurance companies in helping patients decide what hospital they'll use. This comes just as the increasingly demanding consumer is trying to learn more about how he or she will fare as a patient.

Best's Review
August 1, 2003
Critical condition: the nursing shortage is sparking new interest in nurses' liability insurance and maybe higher prices; Property/Casualty; Industry Overview
A national nursing shortage that's nearing a critical level is increasing the responsibilities and liability risks nurses face.
An example of the growing number of medical-liability suits against nurses is a case involving a 78-year-old woman who was badly burned by a steam vaporizer. The nurse responsible for leaving the vaporizer by the woman's bedside was found negligent for failing to safeguard and protect her patient from foreseeable danger.
As the nursing shortage escalates, some industry experts believe that low staffing is leading to increased sales of nurses' and hospital liability policies and might be a factor in rising premiums.
Looming Problem
Although there are nearly 2.5 million registered nurses employed in the United States today, nearly 1.75 million more nurses will be needed to fill vacant positions by 2010.

Canadian Healthcare Manager
August, 2003
A changing paradigm: it's time to consider ehealth investments in terms of Return on Patient Safety
Traditionally, the healthcare sector has framed discussions and investment decisions regarding information technology (IT) in primarily financial terms. In particular, the potential of IT to provide a Return on Investment (ROI) through the automation of certain functions or its ability to decrease unnecessary tests and time-consuming paperwork has been the focus.

Managed Care Weekly Digest
July 28, 2003
ELECTRONIC MEDICAL RECORDS: Group agrees on healthcare data standards
Connecting for Health, a collaboration of more than 100 public and private stakeholders representing every part of the healthcare system, recently released the results of their efforts to bring electronic connectivity to healthcare to improve patient care, lower costs, and protect privacy.
Their achievements in just 9 months toward the adoption of healthcare data standards represents progress that has eluded the healthcare industry for more than a decade. Despite a pace and a set of goals that many thought hard to achieve, Connecting for Health announced unprecedented progress in several key areas including:
1) Achieving consensus on an initial set of healthcare data standards and commitment from more than 50 national healthcare leaders, including a number of federal government agencies to adopt;
2) Identifying and studying a number of noteworthy privacy and security practices in order to describe and disseminate feasible solutions currently in use;
3) Defining the key characteristics and benefits of consumer-controlled Personal Health Records (PHRs), addressing consumer concerns to allow people to have better access to their health information.
Connecting for Health was convened by the Markle Foundation to serve as a catalyst for changes that can rapidly clear the way for the private and secure use of health information to improve quality, patient safety, and enable patients to become better partners in their care. The Markle Foundation provided the initial funding of $2 million for Connecting for Health.

MarketWatch
July 21, 2003 Monday
It's time to digitize healthcare
EDITOR'S NOTE: Mike Ruettgers is Executive Chairman of EMC Corp. (EMC)
HOPKINTON, Mass. (CBS.MW) -- State lawmakers have gathered in San Francisco this week for the 28th annual meeting of the National Conference of State Legislators to tackle the daunting and urgent agenda of budget shortfalls, exploding healthcare costs, education funding, and terrorism preparedness.
A new fiscal survey by the National Governors Association found that 37 states have been forced to reduce their already enacted budgets by nearly $14.5 billion-the largest spending cut since 1979. And the future is not looking any brighter. According to the Center on Budget and Policy Priorities, the states face deficits for the 2004 fiscal year that exceed $70 billion.

Milwaukee Journal Sentinel
July 19, 2003 Saturday FINAL EDITION
A blueprint for patient safety; Planned layout of new facility near West Bend hailed as revolutionary
Health care industry officials throughout the United States are describing the design of a new St. Joseph's Community Hospital of West Bend as the blueprint for a revolution in patient safety.
No other entire hospital has been designed room by room and floor by floor with a primary focus on preventing medical errors and infections and providing a safe, quiet healing environment.
"This is revolutionary," said Robert Krawisz, executive director of the National Patient Safety Foundation in Chicago. "It really is a breakthrough in hospital design."

Lancaster New Era
July 18, 2003, Friday
'Yes' marks the spot; Write on! With medical errors alarmingly on the rise, local hospitals are requiring patients to label surgical sites before operations.
Nick Mondo took a blue pen this morning, leaned down and wrote the word "YES" on his left leg, just below his knee, as he sat on a bed in the presurgical area at Lancaster General Hospital.
"Should I draw an arrow?" the 21-year-old masonry worker from Reamstown asked a nurse.
Mondo was getting screws and plates put in his left ankle, which has been in a cast since he broke it in a car accident Friday. The arrow wasn't necessary, a nurse told him, but the "YES" was.

Tampa Tribune
July 12, 2003, Saturday, FINAL EDITION
Information Technology Decreases Medical Malpractice
Gov. Jeb Bush and the Florida Legislature are in the midst of a contentious debate about how to treat the medical liability disease that has infected the providers of health care. Their treatment argument revolves around how much money to dispense to salve the pain created by mistakes or malicious acts.
What if the majority of the events that are subject of the seemingly intractable "malpractice" debate were found to be not individual practitioner errors or evil at all? What if these "mistakes" were really artifacts of a health care industry that has expanded knowledge beyond the capacity of the provider to know and do?

Federal Document Clearing House Congressional Testimony
July 9, 2003 Wednesday
Committee: Senate Joint Economic
Costs of Health Technology
Statement of Mark McClellan, M.D., Ph.D. Commissioner - U.S. Food and Drug Administration (FDA)

Committee on Senate Joint Economic
July 9, 2003
Good morning Mr. Chairman and Members of the Committee. I am Dr. Mark B. McClellan, Commissioner of Food and Drugs, and I welcome this opportunity to testify before the Committee today. As we enter the 21st century, America leads the world in developing and commercializing new medical innovations and technologies. From information technology to biotechnology to materials science, United States (U.S.) scientists and high technology workers are making new discoveries and developing new products every day that are steadily improving the quality of our lives. This progress is critical to our health and our economic prosperity.

AORNJournal
July 1, 2003
Incident reports--their purpose and scope; Home Study Program.
Editor's note: This is the first of a two-part series on incident reports. Part II, which is scheduled for the August 2003 issue of the AORN Journal will discuss correction processes and how to reduce errors.
Horrible headlines in the mass media about medical errors are rampant these days. Everyone has read or heard about the wrong surgery being performed on a child or the wrong side of a brain being operated on by a neurosurgeon. What about the patient who died from an overdose of chemotherapy? These stories captivate people and send chills down their spines because that patient could have been them or a family member. (1)
Patients today are savvy, educated consumers who are concerned about the potential for acquiring an infection, the level of care they receive, and the qualifications of their health care providers. They believe that most medical errors are the result of the carelessness or negligence of their health care providers, whom they believe to be overworked, worried, or stressed. (2) Most Americans, however, do not understand fully the breadth of health care issues. Health care today is a complex system comprised of numerous intricate parts that interact with multiple other parts in unexpected ways. Various levels of specialization and interdependencies exist in institutions. This places health care facilities at high risk for accidents. (1,3)

TheBBI Newsletter
July 1, 2003
Nursing shortage has multifaceted impact on critical-care areas.
SAN ANTONIO, Texas -- The American Association of Critical-Care Nurses (AACN; Aliso Viejo, California) held its 30th annual National Teaching Institute (NTI) for the first time ever in San Antonio in mid-May. In light of continued national security advisories and travel hassles, the AACN was concerned that attendance would be down but was pleased that there were some 6,000 attendees. The focus on the previously acknowledged nursing shortage was evident throughout the event. According to a March 2000 study conducted by the Department of Health and Human Services, there are 403,527 nurses in the U.S. who care for critically ill patients in a hospital setting. Of this number, 201,833 work at least half time in an intensive care unit, while 70,241 work at least half time in a step-down or transitional care unit, 94,912 work at least half time in an emergency department and 36,541 work at least half time in post-operative recovery units (Table 4). Critical-care nurses comprise about 31% of the total number of nurs es working in asetting.

The BBI Newsletter
July 1, 2003
Nursing shortage has multifaceted impact on critical-care areas.
SAN ANTONIO, Texas -- The American Association of Critical-Care Nurses (AACN; Aliso Viejo, California) held its 30th annual National Teaching Institute (NTI) for the first time ever in San Antonio in mid-May. In light of continued national security advisories and travel hassles, the AACN was concerned that attendance would be down but was pleased that there were some 6,000 attendees. The focus on the previously acknowledged nursing shortage was evident throughout the event. According to a March 2000 study conducted by the Department of Health and Human Services, there are 403,527 nurses in the U.S. who care for critically ill patients in a hospital setting. Of this number, 201,833 work at least half time in an intensive care unit, while 70,241 work at least half time in a step-down or transitional care unit, 94,912 work at least half time in an emergency department and 36,541 work at least half time in post-operative recovery units (Table 4). Critical-care nurses comprise about 31% of the total number of nurs es working in a hospital setting.

FDA Consumer
July 1, 2003
FDA works to reduce preventable medical device injuries.
Medical devices help to alleviate pain, overcome disability, and sustain life. They also, on occasion, fail to operate properly or are misused in ways that are associated with injuries and deaths.
Betty Davis' wheelchair, for example, caught fire, badly burning over 25 percent of her body in January 1999. A quadriplegic confined to a wheelchair since 1976, the 65-year-old Tucson, Ariz., resident knows the importance of a well-maintained machine that works as intended. "I'm a very active quad," she says, but when the fire started, "all I could do was sit there and watch my arms and legs burn."
Faulty wiring short-circuited the battery charger in Davis' wheelchair. Davis says she put the chair on charge after a blinking light indicated the battery was running low. But Davis detected a spark, and immediately disconnected the charger. The spark, however, turned into a flame. Though authorities don't know why, Davis' attempt to reach 911 through her emergency medical pendant failed. Fortunately, a neighbor was nearby at the time and threw water on her to extinguish the fire.

Healthcare Financial Management
July 1, 2003
Whistle-blowing: does anyone want to hear? Leadership and Management; healthcare organizations should be more open to whistle-blowing from employees
The public outcry over the deceptive accounting practices of companies such as Enron and WorldCom last year led some observers to question why no one blew the whistle on these activities earlier. Ralph Nader responded, "What amazes me is that there are thousands of people who could have been whistle-blowers, from the boards of directors to corporate insiders to the accounting firms to the lawyers working for these firms to the credit-rating agencies.
All these people! Would a despotic dictatorship have been more efficient in silencing them and producing the perverse incentives for them all to keep quiet? The system is so efficient that there's a total silence. I mean, the Soviet Union had enough dissidents to fill Gulags." (a)
Nader's comments are disturbing. The healthcare industry has experienced its share of confidence-eroding events:
* The Allegheny Health, Education and Research Foundation (AHERF) declared bankruptcy, and its former CEO was sentenced to prison for using restricted assets to keep the not-for-profit organization afloat.

New Jersey Law Journal
June 23, 2003
Whose Malpractice Crisis Is It, Anyway? Lawyers, doctors and insurers debate the proposed cap on verbal damages
The following are excerpts from a roundtable discussion held May 27 at Columbia Law School entitled, "The Colliding Realities of the Medical Liability Insurance Crisis." A focus of debate was H.R. 663 the bill to cap noneconomic damages in medical negligence cases, which was passed by the House of Representatives in March and is pending in the Senate. Each side was represented by a lawyer, a doctor and an expert on the insurance industry. The moderators were William Sage, M.D., J.D., a professor at Columbia Law School, and David Hechler, a staff reporter with the National Law Journal. The full Webcast is at www.law.columbia.edu.
Participants in Favor of the Bill:
Victor Schwartz is a partner in the Washington office of Shook, Hardy & Bacon of Kansas City, Mo., and is general counsel of the American Tort Reform Association.
Dr. Yank Coble is president of the American Medical Association and an endocrinologist in Jacksonville, Fla.

American Society of Law & Medicine, Inc. Journal of Law, Medicine & Ethics
June 22, 2003
A dose of our own medicine: alternative medicine, conventional medicine, and the standards of science; Ninth Annual Thomas A. Pitts Memorial Lectureship in Medical Ethics, Medical University of South Carolina in Charleston
The discussion about complementary and alternative medicine (CAM) is sometimes rather heated. "Quackery!" the cry goes. A large proportion "of unconventional practices entail theories that are patently unscientific." (1) "It is time for the scientific community to stop giving alternative medicine a free ride. There cannot be two kinds of medicine--conventional and alternative. There is only medicine that has been adequately tested and medicine that has not, medicine that works and medicine that may or may not work" (2) "I submit that if these treatments cannot withstand the test of empirical research, ... then we have wasted a lot of time and effort. The time has been wasted on all the people who have spent years learning falsehoods about acupuncture points and the principles of homeopathy. And the patients have wasted their time, money, and efforts receiving treatments that were not what they were represented to be or were harmful." (3)
On a more conciliatory note, it is often proposed that some CAM modalities may be acceptable, but only those that stand up to the test of science. For instance, the White House Commission on Complementary and Alternative Medicine Policy, established in March 2000 by President Bill Clinton, concluded that "conventional and CAM systems of health and healing should be held to the same rigorous standards of good science." (4) More precisely, "[t]he same high standards of quality, rigor, and ethics must be met in both CAM and conventional research, research training, publication of results in scientific, medical, and public health journals, presentations at research conferences, and review of products and devices." (5)

Iowa City Press-Citizen
June 20, 2003 Friday
Nursing shortage endangers patients through medical errors
Though a tragic mistake that takes or shortens a patient's life sometimes makes the news - as it did recently with the widely reported death of an organ transplant patient - Americans expect to leave hospitals having received excellent care and well on the way to recovery. That's an increasingly dubious expectation as the nursing shortage advances from severe to critical.
Hospital staff nurses say the shortage is now the biggest problem in hospitals today, putting both patients and nurses at risk. There are more than 130,000 registered nurse vacancies today, and the U.S. Bureau of Labor Statistics projects that by 2010 the total number of job openings will exceed a million. In Iowa, there already are vacancies for an estimated 2,600 registered nurses, 700 licensed practical nurses and 2,600 non-licensed nursing support personnel.

Florida Times-Union (Jacksonville, FL)
June 14, 2003 Saturday, Georgia Edition
LEGISLATURE King, James
Senate President Jim King already has declared the special session next week to be an exercise in futility and it hasn't even begun.
But, it does not have to be futile.
There are 13 votes in favor of the plan by Gov. Jeb Bush to address the medical malpractice insurance crisis, according to headcounters. They include stalwart Republican Sen. Steve Wise of Jacksonville.

Star Tribune (Minneapolis, MN)
June 12, 2003, Thursday, Metro Edition
Coleman panel studies medical errors; Experts call for "relentlessly high standards for patient safety" in health care.
Less than two weeks after a state report linked a 2-year-old's death to an accidental overdose in one of his hospitals, Fairview Health Services Chairman David Page told a congressional subcommittee Wednesday that his hospital's systems had failed.
"We're not certain how or whether the overdose may have contributed to her death," Page told the Senate's Permanent Subcommittee on Investigations, chaired by Sen. Norm Coleman, R-Minn. "We are certain that our systems allowed a tenfold overdose and failed a conscientious staff, a patient and the patient's family."

FDCH Political Transcripts
June 11, 2003 Wednesday
Type: Committee Hearing
Committee: Permanent Subcommittee on Investigations
U.S. Senator Norm Coleman (R-mn) Holds Hearing on Patient Safety
Speaker: U.S. Senator Norm Coleman (R-mn), Chairman
Location: Washington, D.c.
Witnesses: Roxanne Goeltz, Burnsville, Minnesota Dr. James P. Bagian, M.d. P.e., Director, National Center for Patient Safety, U.s. Department of Veterans' Affairs Dr. Dennis S. O'leary, M.d., President, Joint Commission on Accreditation of Healthcare, Organizations Dr. Carolyn M. Clancy, M.d., Director, Agency for Healthcare Research and Quality, U.s. Department of Health and Human Services David R. Page, President & Chief Executive Officer, Fairview Health Services, Minneapolis, Minnesota Robert E. Krawisz, Executive Director, National Patient Safety Foundation Dianne Mandernach, Commissioner, Minnesota Department of Health Dr. Suzanne Delbanco, Ph.d., Executive Director, the Leapfrog Group

U.S. Senate Governmental Affairs Committee: Permanent Subcommittee on Investigations Holds a Hearing on Patient Safety
June 11, 2003
Speakers: U.S. Senator Norm Coleman (R-mn) Chairman U.s. Senator Ted Stevens (R-ak) U.s. Senator George V. Voinovich (R-oh) U.s. Senator Arlen Specter (R-pa) U.S. Senator Robert F. Bennett (R-ut) U.s. Senator Peter Fitzgerald (R-il) U.s. Senator Richard C. Shelby (R-al) U.s. Senator John E. Sununu (R-nh) U.s. Senator Carl Levin (D-mi) Ranking Member U.s. Senator Daniel K. Akaka (D-hi) U.s. Senator Richard J. Durbin (D-il) U.s. Senator Thomas R. Carper (D-de) U.s. Senator Mark Dayton (D-mn) U.s. Senator Frank Lautenberg (D-nj) U.s. Senator Mark Pryor (D-ar)
COLEMAN: This hearing is called to order. I'll begin my opening statement, and then turn to the distinguished ranking member of this committee, Senator Levin. And then we'll go to the testimony of the witnesses.

National Law Journal
June 9, 2003
Whose malpractice crisis? Doctors, lawyers and insurance experts debate a $250,000 cap on non-economic damages in medical negligence suits.
This newspaper and Columbia Law School co-sponsored a roundtable debate on May 27, "The Colliding Realities of the Medical Liability Insurance Crisis." The moderators were William Sage, M.D., J.D., a professor at Columbia Law School, and National Law Journal staff reporter David Hechler. A focus of the discussion was the bill in Congress that would cap noneconomic damages in medical negligence cases. It passed in the House of Representatives in March and is pending in the Senate. Each side was represented by a lawyer, a doctor and an expert on the insurance industry. Excerpts appear below. The full Webcast is at www.law.columbia.edu.
David Hechler: If a bill that caps noneconomic damages in medical negligence cases becomes federal law, how will it affect doctors, patients, lawyers and insurance companies?
Dr. Richard Anderson: Patients will have access to critical care, to emergency care, to innovative procedures when they need them. And they will have access across the United States-not only in those favored venues that have already enacted these tort reforms. Insurers will be able to provide a stable market for the sale of medical malpractice insurance. Lawyers would live in a world in which they could still make a good living as medical malpractice attorneys, but they would not be able to become infinitely wealthy, while continuing to lose 80% of their cases.

Telegraph Herald (Dubuque, IA)
June 6, 2003 Friday
Neck manipulation study flawed
Ricketts Clinic of Chiropractic, 1400 University Ave.
The article, "Study: Neck manipulations contribute to stroke" (May 19) provides little useful information and needlessly alarms the public about a safe and effective form of alternative health care.

Business Wire
June 5, 2003, Thursday
Connecting For Health Unites Over 100 Organizations To Bring American Healthcare System into Information Age
   Connecting for Health:
   -- Group Agrees on Healthcare Data Standards; Identifies Noteworthy Privacy and Security Practices and Defines Personal Health Records
   -- Demonstration Project Unveiled to Save Lives, Reduce Medical Errors, and Accelerate Detection of Bioterrorism
   -- Survey Results Find that Consumers Want Doctors to Share Health Information With Them and Protect Their Privacy
   Connecting for Health, an extraordinary collaboration of more than 100 public and private stakeholders representing every part of the health care system, today released the results of their efforts to bring electronic connectivity to healthcare to improve patient care, lower costs and protect privacy. Their achievements in just nine months toward the adoption of healthcare data standards represents progress that has eluded the healthcare industry for more than a decade. Despite a pace and a set of goals that many thought hard to achieve, Connecting for Health announced unprecedented progress in several key areas including:
   -- Achieving consensus on an initial set of healthcare data standards and commitment for their adoption from a wide variety of national healthcare leaders, including a number of federal government agencies;
   -- Identifying and studying a number of noteworthy privacy and security practices in order to describe and disseminate feasible solutions currently in use;
   -- Defining the key characteristics and benefits of consumer-controlled Personal Health Records (PHRs), addressing consumer concerns to allow people to have better access to their health information.

The Morning Call, Inc. Morning Call (Allentown, PA)
June 1, 2003 Sunday FIRST EDITION
Preventive medicine; Hospitals try a variety of high- and low-tech methods to cut down on mistakes.
It used to be a joke patients played on their surgeons -- writing "cut here" on a body part before an operation.
   Now, it's a requirement at area hospitals and surgery centers.
   To prevent potentially deadly medical mistakes and costly lawsuits, health care workers are trying every prescription in the medicine cabinet -- from inexpensive markers to multimillion-dollar scanners.
   Whether the gadgets are a better way to make hospitals safer than bolstering the nursing staff -- a need physicians say is crucial -- remains in question. But markers, bar-coded identification bracelets and ATM-like medicine dispensers are appearing on patient floors for good reason.

Dolan Media Newswires The Daily Record of Rochester (Rochester, NY)
May 29, 2003 Thursday
Monroe County Bar Assn. panel debates tort reform legislation
Members of the legal and medical community shared their thoughts on medical malpractice legislation and the current tort reform proposals in a panel discussion hosted by the Monroe County Bar Association on Thursday, May 22, 2003.
The discussion focused on proposed legislation at both the state and federal level which would cap the noneconomic losses, or pain and suffering damages, in medical malpractice cases at $250,000. Current federal legislation has passed in the House of Representatives and is now before the U.S. Senate. A similar bill is pending before the State Senate and Assembly.

Rochester Democrat and Chronicle All Rights Reserved Rochester Democrat and Chronicle
May 27, 2003 Tuesday
BUSINESS OF HEALTH
Reduce medical errors to cut malpractice insurance rates. Stephen G. Schwarz Guest Essayist
In a recent Speaking Out essay, Drs. Steven Hanks and Derek tenHoopen alleged that medical malpractice suits are draining the life out of health care in this state. They make a variety of statements that require a response because these statements are unsupported by the facts.
Drs. Hanks and tenHoopen allege that up to half of the dollars awarded in liability cases in New York state wind up in the hands of trial attorneys rather than in the pockets of the injured.

Newsday, Inc. Newsday (New York)
May 21, 2003 Wednesday NASSAU AND SUFFOLK EDITION
Rx for Lawsuit Pain?; Docs rally for laws setting limits on malpractice awards
Under the shade of pine trees at Heckscher Park in Huntington, at least 200 doctors in white coats gathered to get out a dire message. Unless there's medical malpractice reform, they threatened there will be fewer obstetricians to deliver babies, fewer qualified individuals becoming physicians and more patients possibly dying.
They said this despite statistics showing that New York State has no shortage of physicians. The demonstration was one of 21 yesterday organized by the Medical Society of the State of New York. One was in Nassau, at Eisenhower Park in East Meadow. Many doctors canceled their afternoon appointments in order to attend.

InformationWeek
May 19, 2003
Mission: Critical
-- Imagine 30% fewer deaths in intensive-care units and half the medication errors in hospitals. IT is poised to deliver improved patient care.
Dr. Daniel Ikeda is about two miles away, trying to monitor the well-being of more than two dozen patients, including the one in trouble. Ikeda and a registered nurse sit at workstations, scanning several computer displays of information, including real-time vital signs in what's called the electronic intensive-care unit. An alert sounds, signaling that the patient's vital signs have changed. Ikeda checks what surgery has been done and can even look at the patient using a Webcam in the room. He calls a nurse on the floor to start intravenous fluids and a stronger antibiotic, and he tells an assistant to call a surgeon. Emergency surgery begins around midnight.
Texas Lawyer
May 19, 2003
Does Texas Need Tort Reform and How Much Is Enough?
Editor's note: The Texas Legislature is poised to pass a tort reform bill before it adjourns on June 2. A bill passed by the House and a bill considered by the Senate would make several changes in how suits are tried, including greater caps on damages and a new, lower interest rate on judgments. The proposals also address an offer of settlement rule and new rules for class-action suits. The changes are controversial, with litigators on the two sides of the docket agreeing on little about the proposals and whether they're necessary in Texas. On May 5, Texas Lawyer brought five Texas lawyers together in Austin for a roundtable discussion on tort reform. The lawyers talked about the need for tort reform, how proposed caps on damages would be applied and the value of changes in the jury system. A transcript of the discussion, edited for length and style, follows. Part two of the discussion will appear in the May 26 issue of Texas Lawyer.
Texas Lawyer: . . . Brenda Sapino Jeffreys, senior reporter,
Do we need tort reform in Texas, and why? And how much tort reform is the right amount?

The Christchurch Press
May 15, 2003 FT-ACC-NO: A20030516200-4A75-GNW
DATA IS SKIN DEEP
Would you put a microchip under your skin that gives access to personal data? There are medical benefits, but privacy concerns, too, writes DAVID KILLICK.
I've got you ... under my skin." New technology gives the old Cole Porter song new meaning.

Rochester Democrat and Chronicle
May 14, 2003 Wednesday
The headline reads: Can you read your doctor's handwriting?
Seminar will coach medical pros on improving penmanship.
   by Staff Writer   Matt Leingang
   Some will be shamed. Others might scoff at being treated like second-graders.
   But when dozens of local doctors show up at a seminar Thursday to improve their handwriting, they will tackle one of the medical profession's most serious, and sometimes deadly, problems: illegible penmanship.

Medical Economics
May 9, 2003
Tort reform isn't enough: It may help fix the malpractice crisis, but it won't prevent medical errors and system failures; The Way I See It.
President Bush, congressional leaders, and the American Medical Association rightly claim that our medical liability system is broken, and needs repair. One major reason, they believe, is that the courts are overrun by frivolous lawsuits, resulting in outrageously high awards that are driving up malpractice premiums, and causing physicians to flee certain states.
In fact, there are few truly frivolous malpractice claims--meaning those wholly without merit. Frivolous litigation does flourish in workers' compensation, auto accident, and product liability cases, but it's relatively rare in medical liability.

News Observer (Raleigh, NC)
May 8, 2003 Thursday, FINAL EDITION
Hospitals are curing mistakes
CHAPEL HILL -- We have experienced tremendous advances in health care during the past century. In 1900, the average man in the United States lived 46.3 years; the average woman 48.3 years. One hundred years later, the average man lives 73.9 years and the average woman 79.4 years. This reflects a tremendous increase in our understanding of disease and in treatment options.

The Miami Herald
May 6, 2003, Tuesday
Study reveals widespread medical, prescription errors in 5 countries
MIAMI _ One-fourth of patients with health problems in five countries say they suffered from a medical mistake or prescription error in the past two years, a Harvard-led study reports in an issue of Health Affairs published Tuesday.
   Medical errors have been a hot topic for the past three years, since the Institute of Medicine estimated that mistakes may kill 44,000 to 98,000 Americans a year.
   The latest report shows the problems persist in countries with widely different health systems _ and get worse the more doctors a patient sees.
   Of those who visit three or more doctors a year, the study found, one in three surveyed said they had suffered from a medication or medical error.

The State Journal-Register (Springfield, IL)
May 5, 2003 Monday
Speak your mind; Memorial Medical Center's 'It's OK to Ask' program promotes better interaction between patients, caregivers
Memorial Medical Center wants its patients to ask questions about their care and not feel bashful when requesting help.
   But such revelations should make it no surprise that Memorial is promoting greater interaction between sick people and their busy caregivers through a new program called, "It's OK to Ask."
   St. John's Hospital has adopted the "Speak Up" title in its own patient-safety program.
   "Health care for a long time has been somewhat less than patient-focused," said James Bente, Memorial's vice president for quality and organizational development. "That's a strange thing to say ... but we really didn't involve them closely in their care."

U.S. Government Printing Office FDA Consumer
May 1, 2003
Strategies to reduce medication errors: how the FDA is working to improve medication safety and what you can do to help; Cover Story; Cover Story
When Jacquelyn Ley shattered her elbow on the soccer field two years ago, her parents set out to find her the best care in Minneapolis. "We drove past five other hospitals to get to the one we wanted," says Carol Ley, M.D., an occupational health physician. Her husband, an orthopedic surgeon, made sure Jacquelyn got the right surgeon. After a successful three-hour surgery to repair the broken bones, Jacquelyn, who was 9 at the time, received the pain medicine morphine through a pump and was hooked up to a heart monitor, breathing monitor, and blood oxygen monitor. Her recovery was going so well that doctors decided to turn off the morphine pump and to forgo regular checks of her vital signs.
Carol Ley slept in her daughter's hospital room that night. When she woke up in the middle of the night and checked on her, Jacquelyn was barely breathing. "I called her name, but she wouldn't respond," she says. "I shook her and called for help." The morphine pump hadn't been shut down, but had accidentally been turned up high. The narcotic flooded Jacquelyn's body. She survived the overdose, but it was a close call. "If three more hours had gone by, I don't think Jacquelyn would have survived," Ley says. "Fortunately, I woke up."

NEA Today
May 1, 2003
Preventing medical errors: NEA and the AFT team up to address troubling healthcare issue; News; National Education Association; American Federation of Teachers
When 17-year-old Jesica Santillan died Feb. 22 after receiving transplanted organs with the wrong blood type, her death made headlines across the country. But the same day, with little or no publicity, about 250 other people also died in U.S. hospitals as the result of medical errors--mistakes which, like the one that killed Santillan, could have been prevented.
Between 44,000 and 98,000 people die each year because of medical errors during hospitalizations, according to a 1999 report from the Institute of Medicine of the National Academy of Sciences. Even at the low end of that range, the report noted, those numbers make medical errors the nation's eighth leading cause of death, slightly ahead of car accidents.

PR Newswire
April 29, 2003, Tuesday
Leading Health Industry Experts Offer Seven-Step Solution For Safer, Better, and More Accountable Health Care; Authors George C. Halvorson of Kaiser Permanente and George J. Isham, MD, Of HealthPartners Examine the Impending Health Care Crisis -and Provide a Way to Solve It
Americans receive some of the best medical care in the world, but the "miracles of modern medicine" often are applied inconsistently, unsafely -- and at a price tag that is putting those miracles out of reach for many purchasers and patients. Understanding the dynamics of health care and how we solve the current health care crisis are the subjects of the new book, Epidemic of Care: A Call for Safer, Better, and More Accountable Health Care. The authors, George C. Halvorson, chairman and chief executive officer of Kaiser Foundation Health Plan and Hospitals, and George J. Isham, M.D., medical director and chief health officer of HealthPartners, represent two of the nation 's leading and most esteemed nonprofit health care organizations. Halvorson and Dr. Isham draw upon their 50 years of combined leadership experience in health care to examine in plain speech why health care costs so much, and why the results are so inconsistent. Delving deeper into the issues surfaced by a landmark Institute of Medicine report -- which revealed that between 44,000 and 98,000 Americans die each year in hospital accidents -- the authors discuss a number of insightful findings from recent health care journals and reports. Most importantly, the authors take a hard look at what Americans are really buying for their health care dollars:
* Fewer than 10 percent of patients with congestive heart failure receive the care they need. The remaining 90 percent are significantly more likely to suffer unnecessarily and die too soon because they didn't receive best care.

Business Wire
April 25, 2003, Friday
VeriChip Subdermal Personal Verification Microchip to Be Featured at IDTechEX ''Smart Tagging in Healthcare'' Conference in London, April 28-29, 2003
   International Audience Will Also See First-Ever Demonstration of Implantable Temperature-Sensing Microchip and Learn about Potential Human Healthcare Applications
   Applied Digital Solutions, Inc. (Nasdaq: ADSX) an advanced technology development company, announced today that its wholly owned subsidiary, VeriChip Corporation, has been invited to make two presentations at the upcoming IDTechEx "Smart Tagging in Healthcare" conference in London, April 28-29, 2003.
   Dr. Richard Seelig, Vice President of Medical Applications for VeriChip Corporation, will provide a live demonstration of VeriChip(TM) and discuss its potential healthcare applications - which are subject to regulation by the US Food and Drug Administration - including:
   -- Implanted medical device identification
   -- Emergency access to patient-supplied health information
   -- Portable medical records access
   -- In-hospital patient identification
   -- Medical facility connectivity via patient
   -- Patient/therapy integration
   -- Inter-facility patient identification
   -- Additional healthcare applications which are not Internet dependent, including disease/treatment management of at-risk populations
   Dr. Seelig will also provide the first-ever public demonstration of a new temperature-sensing microchip technology, marketed, patented and first announced by Digital Angel Corporation (AMEX: DOC) in February 2003. This new Radio Frequency Identification (RFID) microchip has similar dimensions and performance characteristics as VeriChip, but it can also obtain and transmit body temperature data.
   This technology for human healthcare applications is subject to appropriate regulations in the US and other jurisdictions. The potential healthcare applications of the new temperature-sensing microchip include, but are not limited to, the following broad treatment categories:
   -- Chemotherapy treatment management

Charleston Daily Mail (West Virginia)
April 25, 2003, Friday
Letters to the Editor There needs to be a memorial to malpractice victims

According to a National Academy of Sciences' Institute of Medicine report, between 44,000 and 98,000 Americans die in hospitals each year as a result of medical mistakes - more than those who die of car accidents, breast cancer or AIDS.
I suggest that we build a Malpractice Memorial modeled after the Vietnam Memorial.

The Tennessean
April 25, 2003 Friday 1st Edition
LETTERS TO THE EDITOR
Malpractice is caused by doctors, not lawyers
   To the Editor:
   Since Sen. Bill Frist asked to be addressed as doctor rather than as senator, it should come as no surprise to his constituents to hear him singing the medical profession's anthem when addressing the issue of malpractice tort reform.
   ***
   It is instructive to listen to lyrics of this anthem sung by other tort reform proponents.
   A Massachusetts doctor held a sign that read, "If your doctor is not there, will your lawyer deliver your baby?" That might not be a bad idea since between 44,000 and 98,000 Americans die in hospitals each year as a result of medical mistakes.
   Incredibly, a South Carolina doctor said in reference to a victim who lost both breasts after being misdiagnosed with breast cancer, "She'll have breast reconstruction better than she had before." That statement is unforgivably insensitive.

Los Angeles Times
April 21, 2003 Monday Home Edition
Series of Errors Led to Girl's Death, State Says; The toddler entered UCLA Medical Center for routine surgery, but never recovered.
    Just over a year ago, 16-month-old Delaney Lucille Gonzalez walked with her family into UCLA Medical Center for routine surgery to repair a cleft palate.
   Three days later, she was disconnected from life support and died in her mother's arms.
   "To bring a healthy child in there for surgery so minor," her mother, Jodi, said recently, clutching a headband she had made for Delaney, "you just don't accept that she's going to die."
   The simple explanation is that a breathing tube had been misplaced and had pumped air into the child's stomach rather than her lungs, according to Delaney 's medical and autopsy records. Because her body was deprived of oxygen, Delaney 's heart stopped. She suffered irreversible brain damage.

News & Record (Greensboro, NC)
April 20, 2003 Sunday ALL EDITIONS
MALPRACTICE DEBATE: TREAT THE ILLNESS
In a North Carolina hospital, doctors fail to diagnose a common, highly treatable case of jaundice in a newborn. When the oversight is discovered, it is too late. She suffers irreparable brain damage. She cannot talk. She is confined for the rest of her life to a wheelchair and must be fed through a tube. The projected costs of a lifetime of assisted care: $17 million.
In Minnesota, surgeons remove both breasts of a 46-year-old woman who does not have cancer. The hospital confused her biopsy results with someone else's.

April 8, 2003 Tuesday Five Star Late Lift Edition Correction Appended
CARE MEANS MORE THAN CAPS
    MEDICAL MALPRACTICE
   * By pursuing excellence, instead of making excuses, doctors can sharply reduce errors, cut costs and boost public confidence.
   The debate over legislation limiting the size of malpractice awards has turned into an emotional battle between doctors and lawyers. It would be easier to root for physicians if lawsuits had not been so important in pushing providers to confront quality problems.
   As medical historian James Mohr has written, malpractice litigation was in many ways a direct consequence of a professional failure to enforce standards. Patients had no alternative but to "try to hold individual practitioners, one at a time, to whatever standards they or their lawyers, one at a time, wanted to impose."

Medical Post
April 8, 2003
Factoring for humans: anesthesiologists have led the way at designing medical devices to reduce human error -- but other specialties are following
The airline and nuclear industries have long understood the importance of designing their systems to account for human nature. In comparison, another ''safety-critical'' field--medicine--has for the most part been slow to catch on.
But the often problematic interaction between people and health-care technology is getting more attention in the wake of the U.S. Institute of Medicine's 1999 report ''To Err is Human,'' which estimated medical errors kill between 44,000 and 98,000 Americans each year.
Dr. Kim Vicente (PhD), professor and director of the Cognitive Engineering Laboratory at the University of Toronto and a visiting professor at the Massachusetts Institute of Technology, is one of the leading researchers in human factors engineering--the design of technology to suit human needs, rather than expecting people to adapt to the technology.

Morning Star (Wilmington, NC)
April 7, 2003, Monday
Doctors take insurance demands to Raleigh
   His daughter is on the cusp of becoming an OB/GYN - the kind of profession most parents would dream of for their children.
   But Dr. Jim Markworth would prefer she practice in a medical field with a brighter future, he said. The soaring cost of malpractice insurance for obstetrics and gynecology - the health care of women, including during pregnancy and childbirth - will soon be crushing, he said.
   "I'm trying to talk her out of it," he said.

The Ledger (Lakeland, FL)
April 6, 2003, Sunday
CARE QUALITY A CONCERN IN DOCTOR ISSUE; BETTER REGULATION, INFORMATION OPENNESS NEEDED, CRITICS SAY.; MALPRACTICE DEBATE
TALLAHASSEE -- Carl Flatley knows the health-care profession. He was a dentist for 25 years.
But last year, Flatley saw a darker side of medicine when his 23-year-old daughter underwent minor elective surgery in a Pinellas County hospital. Erin, who was a graduate student, developed an infection. It wasn't detected. She wasn 't treated until it was too late. And she died.

Sarasota Herald-Tribune (Florida)
April 6, 2003 Sunday Venice Edition
Efforts to curb medical errors faltering; Consumers remain frustrated at the lack of notice given towards physician; disciplinary issues.
    Carl Flatley knows the health-care profession. He was a dentist for 25 years.
   But last year, Flatley saw a darker side of medicine when his 23-year-old daughter underwent minor elective surgery in a Pinellas County hospital. Erin, who was a graduate student, developed an infection. It wasn't detected. She wasn 't treated until it was too late. And she died.
   "The cause of her death was listed as septic shock, but what really killed her was negligence, arrogance and incompetence," Flatley said.

Poughkeepsie Journal (Poughkeepsie, NY)
April 2, 2003 Wednesday Front Edition
State slow to censure errant doctors
    When Taudrianna Gaton was born five years ago, seven minutes passed before she could be coaxed to breathe -- the result, her attorney says, of seven hours of ignored fetal distress. She was left catastrophically damaged -- she is wheelchair-bound, legally blind and mentally incapacitated.
   In December, a malpractice lawsuit filed against her delivering obstetrician, pediatrician and hospital was settled for $4.1 million, which will be used to provide her care over an expected 80-year lifetime, according to court documents. It may be the largest malpractice payment ever made in Ulster County.
   The success of baby Gaton's case was, it seems, no fluke. In 1999, Dr. Carlos Tejada, a Kingston obstetrician, pleaded guilty to state charges of negligence and incompetence and agreed he would never again deliver babies. One of two cases cited against him was that of Taudrianna Gaton.

Governing Magazine
April, 2003
MEDICAL MAYHEM
When their malpractice insurance rates tripled two years ago, leading doctors in Clark County, Nevada--obstetricians, gynecologists and emergency room physicians--were so angry they walked out on their jobs. Worrying about physicians paying inflated insurance premiums may not have been the highest priority of Nevada legislators, but the threat of pregnant women in Las Vegas driving 50 miles or more to have their babies delivered was. So in the summer of 2002, Governor Kenny Guinn called a special session of the legislature, and it unanimously passed a bill capping non-economic damages--commonly known as pain and suffering--for most malpractice claims. Legislators were assured by both doctors and the insurance companies that the $350,000 cap was the best way to bring stability to the medical malpractice market. They were wrong. Rates kept climbing. "The ink wasn't dry" on the first bill, says Nevada Assembly Majority Leader Barbara Buckley, "before some physicians began an initiative process." Their petition would tighten the pain-and-suffering cap and also impose severe limits on attorney contingency fees--a version of California's 1975 medical malpractice law that many physicians and most insurance companies consider the holy grail. This time around, though, Nevada lawmakers are wary. Since its damage caps failed to lower costs, the legislature is considering stricter regulation of insurance companies.

HealthFacts
April 1, 2003
People are frequently injured by medical errors; Rx News.
It has been two and one-half years since the Institute of Medicine (IOM) issued its groundbreaking report on medical errors. Having been part of the IOM effort, I had high hopes that it would finally force the health care system to confront the crisis in patient safety with a sense of urgency. But as the months go by, I become less and less convinced that a sufficient number of doctors and hospitals are committed to doing whatever is necessary to stem the tide of death due to medical mistakes. Instead, some have chosen to focus on debunking the IOM 's calculations as unscientific and grossly exaggerated, thus denying the problem exists rather than fixing it.
The IOM concluded that between 44,000 and 98,000 hospitalized patients suffer a fatal injury because of medical errors each year. It has responded to its critics by pointing out that this is likely an underestimate of the true dimensions of patient injury for several reasons. First, the IOM's estimate is based on errors only in hospital care. In other words, the type of care that is rapidly shifting into ambulatory settings; and second, medical mistakes are well known to go unrecognized and undocumented in hospital medical records.

News Observer (Raleigh, NC)
March 30, 2003 Sunday, FINAL EDITION
Malpractice fight brews
    For the third time since the 1970s, North Carolina doctors face surging medical malpractice insurance costs.
   And once again, the doctors are warning that if something isn't done to contain their soaring premiums, the problem will affect everyone as physicians quit performing risky services, retire or even leave the state.
   The remedy prescribed by doctors, hospitals and nursing home operators is a law to limit medical malpractice payments for pain and suffering to $ 250,000. The cap, the doctors' groups say, would end "runaway" jury awards and settlements that they say are driving insurance rates up.
   A bill to limit awards was introduced Thursday in the state House of Representatives with the support of the state's largest doctors organization and the backing of 72 lawmakers. A similar bill is pending in the state Senate, where a special committee has been formed to study the issue.

The Herald-Sun (Durham, N.C.)
March 26, 2003, Wednesday
Doctor: Learn from mistakes Expert speaks on patient safety at Duke Hospital
    Though patients are regularly injured or killed from medical errors in American hospitals, most hospitals hide and blame rather than confront and learn, according to a national patient safety expert.
   Effective patient safety systems must establish cultures that focus on learning from mistakes and avoiding unnecessary punishment, said physician James Bajian in a talk to Duke University Medical Center personnel Tuesday.
   Bajian, director of the Department of Veterans Affairs' National Center for Patient Safety, is a former NASA astronaut and engineer who flew on two shuttle missions and supervised the ocean recovery of the capsule following the 1986 Challenger explosion. He is also helping in the investigation of the Columbia shuttle break-up.

Charleston Gazette (West Virginia)
March 22, 2003, Saturday
Legislation to benefit health care in state March 22, 2003, Saturday
The American health-care system is confronting a crisis. The seemingly competing challenges of cost (insurance, prescription drugs, technology and demographics) and quality (safety and effectiveness) must be faced sooner or later. West Virginia is no different from other states, but our task may be greater because of our economy, aging population and the level of high-risk behaviors of our people.
The recent passage of H.B. 2122 (more commonly known as the Medical Malpractice Bill) by the Legislature and subsequent signing by Gov. Wise has been a source of relief to much of the physician community, as well as to what appears to be a majority of the voting public. There are those, however, who feel that the medical community has been given much, but little has been done to oversee marginal physicians, and that the overall quality of medical care could diminish with the advent of significant tort reform.

National Legal Center for the Medically Dependent & Disabled, Inc. Issues in Law & Medicine
March 22, 2003
Quiet killings in medical facilities: detection & prevention.
The purpose of this article is to prompt a public discussion concerning the "quiet killings" that have occurred and are occurring in our medical facilities, hopefully leading to a robust debate over improving methods of detecting and preventing such killings. The importance of this subject cannot be overstated, particularly in light of the ever-increasing numbers of people who will be admitted to, or living in, medical facilities as the first of the "baby boom" generation reaches age sixty-five in the year 2011 (1) and the number of employees who have routine access to these patients or residents. In 2000, hospital admissions were over thirty-three million (2) and in 1999 nursing homes had 1.7 million residents. (3) Hospital employees number over four million and nursing home employees another 1.8 million. (4) To these institutions and people having access may be added the residents of homes licensed to dispense medication and all of the visitors to all of the facilities.
The article will provide evidence of these quiet killings, define the scope of the problem they present, discuss some problems in detecting, investigating and prosecuting these killings, and suggest methods for detecting and preventing the killings. (5) Not only will the implementation of methods for detecting and preventing such killings save lives, such activity will save the reputation (and financial resources) of health care professionals and medical facilities by reducing their exposure to civil and criminal liability.

Federal News Service
March 20, 2003 Thursday
Hearing of the Labor, Health and Human Services and Education and Related Agencies Subcommittee of the House Appropriations Committee
Subject: Health and Human Services Department Fiscal Year 2004 Budget
Chaired By: Representative Ralph Regula (R-oh)
Location: 2358-b Rayburn House Office Building, Washington, D.c.
Witnesses: Tommy Thompson, Secretary, Department of Health and Human Services
REP. RALPH REGULA (R-OH): I'll tell you what, we've got about five minutes. Mr. Secretary, why don't you make your opening statement and then we'll have to recess for votes. Then we'll have -- there'll be two -- there'll be a total of about 25 minutes because we have three votes after your -- but we have a little time before we need to leave.
   MR. THOMPSON: All right.
   REP. REGULA: How much time do you need?
   MR. TOMMY G. THOMPSON: I was going to take 10 minutes. But if you want me just to summarize some things --

Michigan Daily via U-Wire University Wire
March 19, 2003, Wednesday
U. Michigan seeks to prevent medical errors
The death of 17-year-old Jesica Santillan after she mistakenly received incompatible organs during transplant surgery at Duke University Medical Center has heightened concerns among medical providers and patients about medical errors.
"All of us have been saddened and alarmed by the recent event that occurred at the Duke University Medical Center. The only positive outcome I can see from this tragedy is that it serves as a trigger for other transplant programs to re-evaluate their policies and procedures," Darrell Campbell, University of Michigan Hospitals chief of clinical affairs and a chair on the Patient Safety Committee, said in a written statement. "Human error will always be with us, but it is our responsibility as a health system to put enough fail-safe mechanisms in place that errors are detected and remedied before serious harm is done."

Newsday (New York)
March 16, 2003 Sunday NASSAU AND SUFFOLK EDITION
Quest For Answers; Renewed scrutiny of suspected medical errors
    Barbara Desiderio still remembers the 1 a.m. phone call from the hospital, the voice on the other end of the line saying her son's condition had changed.
   By the time she made it from Centerport to the hospital early Dec. 6, 1995, Desiderio's 28-year-old son, Robert Jankowski, who had struggled with asthma since childhood, was dead. And all hospital officials could tell her was that he had suffered a sudden cardiac arrest.
   Years later, when Desiderio scoured her son's medical records, she discovered that hospital staff had given him Propulsid, a heartburn medication with a label warning it was not to be mixed with the antibiotics and antifungals Jankowski was on because it could trigger heart problems and sudden death.
   As the story of 17-year-old Jesica Santillan's botched heart and lung transplant has captured the public's attention in recent weeks, there has been renewed scrutiny brought to what some call an epidemic of medical errors in U.S. hospitals. Shortly after Santillan's first surgery, the Duke University Medical Center transplant team members made the stunning admission that they had violated a basic rule of medicine - forgetting to do a simple check of patient and donor blood type compatibility. Santillan, who was from Mexico, died in Raleigh, N.C., on Feb. 22, two days after receiving a second set of organs.

Dayton Daily News (Ohio)
March 15, 2003 Saturday CITY EDITION
GOOD BILL COVERS BID FOR DAMAGE CAPS
SOMETHING CALLED THE PATIENT SAFETY Improvement Act was put to a vote in the U.S. House of Representatives on Wednesday. It sounds good, and it passed overwhelmingly. Taking it up now was a nice political move.

The Dallas Morning News
March 14, 2003, Friday SECOND EDITION
Fatal Slips; Greater transparency needed in medical cases
An organ transplant gone bad. Blood types that didn't match. A young girl dead. And nearly a year later, no clear answers as to what went wrong, only hospital officials, physicians and lab technicians pointing fingers.

National Journal's CongressDaily
March 13, 2003 Thursday 10:30 am Eastern Time am
SECTION: HEALTH House OKs Medical Error Bill, Takes Up Malpractice Suit Cap
The GOP-controlled House today takes up one of its featured pieces of health legislation this session, a bill to impose federal limits on medical malpractice suits that sponsors say will help lower spiraling malpractice insurance premiums and opponents say will hurt patients.
The bill -- which has passed the House in various forms a half dozen times since Republicans took over the chamber in 1995 -- would cap non-economic "pain and suffering" damages at $250,000. It would also limit attorney fees and cap punitive damages at $250,000 or twice the amount of economic damages, whichever is greater.

Federal Document Clearing House Congressional Testimony
March 13, 2003 Thursday
COMMITTEE: SENATE APPROPRIATIONS CAUSES OF THE MEDICAL LIABILITY INSURANCE CRISIS
Statement of Donald M. Berwick, MD President and CEO Institute for Healthcare Improvement
Committee on Senate Appropriations Subcommittee on Labor, Health and Human Services, Education, and Related Agencies
March 13, 2003
Thank you for the opportunity to testify here. I am President and CEO of a nonprofit organization, the Institute for Healthcare Improvement, whose mission is to accelerate improvement of health care systems. I am also Clinical Professor of Pediatrics and Health Care Policy at Harvard Medical School.
I am here today as a representative of the Institute of Medicine of The National Academies. I serve on the IOM's governing Council, and I was a member of the IOM's Committee on Quality of Healthcare in America, which wrote the two landmark reports on quality, To Err Is Human and Crossing the Quality Chasm. I believe that these and subsequent IOM reports on quality offer this nation, and this Congress, a superb blueprint for the redesign and improvement of our American health care system.

United Press International
March 13, 2003 Thursday
FDA rules could improve patient safety
LEAD: The Food and Drug Administration unveiled two proposed rules Thursday the agency said "are the start of a comprehensive strategy to build a medical patient protection system for the 21st century."
The first would require bar codes on certain drug labels and the second would clarify existing guidelines drug makers must follow to report adverse effects of their products.
FDA said the proposals are in line with a 1999 Institute of Medicine report that cited bar codes as one method that could prevent deaths attributed to medication errors, which seemed to be on the rise. The institute estimated 44,000 to 98,000 deaths occurred per year in the United States because of errors in surgical procedures, devices and medications. About 7,000 of such deaths in 1993 were due to medication mix-ups, the report said.

Facts on File World News Digest
March 12, 2003
Legislation:House Approves Medical Errors Registry; Other Development
The House March 12 passed, 418-6, a bill to create a confidential registry of medical errors voluntarily reported to the federal government. The legislation aimed to lower the incidence of medical mistakes by compiling a database of errors that only health professionals could access, allowing them to learn from the mistakes of their colleagues. Some lawmakers from both parties said the bill did not contain firm enough regulations, and argued that nonmandatory reporting weakened its efficacy. There was widespread agreement, however, that the bill was a good first step.

Sun-Sentinel (Fort Lauderdale, FL)
March 10, 2003 Monday Broward Metro Edition
TORT REFORM NOT THE ANSWER; JURY AWARDS ARE USUALLY APPEALED AND SETTLED FOR LESS
One hot topic on the agenda of the current legislative session is tort reform and a proposal to cap pain and suffering and other non-economic damages in medical malpractice cases at $250,000.
As a registered nurse, I've seen my share of incompetent physicians. Every year, between 44,000 and 98,000 people die as a result of medical mistakes.

News & Record (Greensboro, NC)
March 9, 2003 Sunday ALL EDITIONS
WHO LIVES, WHO DIES, WHO PAYS? JESICA'S SWEET SAD SONG PLAYS ON
Seventeen-year-old Jesica Santillan was put to rest Tuesday, but not the roiling controversy surrounding her tragic death.
Jesica died following an unthinkable transplant error at Duke Hospital. She received a heart and lungs that did not match her blood type. Following a frenetic scramble to undo the mistake, new organs were found and another surgery performed. But it was too late.

Morning Call (Allentown, PA)
March 8, 2003 Saturday FIRST EDITION
Allentown protest faces obstacles; Safety issues hamper demonstration against jury award caps.
    A demonstration against caps on jury awards for pain and suffering staged in front of U.S. Rep. Pat Toomey's Allentown office Friday morning did not go as planned.
   First, the big white bus bearing a blue cutout of the Capitol and a sign blaming high medical malpractice insurance rates "on insurance companies, not injured children" had to be parked in a less conspicuous spot across the street from the private lot at Toomey's building.
   Then, the Emmaus mother and brain-injured daughter who were supposed to represent those harmed by such legislation didn't show because of the cold.

Charleston Gazette (West Virginia)
March 7, 2003, Friday
Tragic Medical nightmare March 7, 2003, Friday

DOWN in rural Mexico, truck-driver Melecio Santillan and his wife had a lovely but sickly daughter, Jesica. Local doctors couldn't cope with her rare heart disorder, so the desperate Santillans paid a "coyote" $ 5,000 to smuggle them into New Mexico. Speaking no English, they made their way to Louisburg, N.C., where relatives lived.

The Post-Standard (Syracuse, NY) March 7, 2003 Friday Final Edition FIXING MEDICAL ERROR A JOB FOR THE PROFESSION
To the Editor:
All conscionable physicians want to eliminate medical errors. Reports of 44,000 to 98,000 deaths a year from errors are indeed disconcerting.

USA TODAY
March 5, 2003, Wednesday, FINAL EDITION
Special report: Hype outraces facts in malpractice debate
The symptoms are popping up in state after state: doctors carrying picket signs, insurers jacking up premiums for malpractice insurance and patients unable to find care. The diagnosis offered by doctors, insurers, state legislatures and President Bush: The nation faces a medical malpractice crisis that is driving insurance so high that some doctors are leaving their practices. The causes, they say, are frivolous lawsuits and runaway jury awards.
Their prescription is tort reform: limits on damages patients can collect for pain and suffering when they persuade a jury that a doctor botched their treatment. Bush is pushing for a federal law that would set a $ 250,000 cap on damage awards for pain and suffering in states that don't already have caps.

The Boston Herald
March 4, 2003 Tuesday ALL EDITIONS
Grieving dad fights malpractice award caps
A Pembroke father of a 3-month-old baby who died after her surgery was delayed took his battle against malpractice award caps to Washington yesterday.
John McCormack joined other patients and activists at the American Medical Association's annual meeting to protest President Bush's proposed $ 250,000 cap on "pain and suffering" malpractice penalties. Bush is expected to speak to the group today on his health care policy prescriptions.

Business Wire
March 4, 2003, Tuesday
PacifiCare Releases First-Ever QUALITY INDEX Profile of Hospitals

   -- Quality and satisfaction ranked at more than 200 California hospitals
   -- Attempt to improve health-care quality and close the variation in quality cited by the IOM
   -- Profile encourages consumers to fully participate in health-care decisions
   PacifiCare of California, a health plan subsidiary of PacifiCare Health Systems Inc. (Nasdaq:PHSY), today became the nation's first health plan to publicly release wide-ranging data on the performance of academic and community hospitals in its networks in terms of quality of care and level of service.
   PacifiCare's QUALITY INDEX(R) profile of Hospitals will provide the health plan's 2 million California members with more detailed information regarding hospital quality and service and provide incentives for hospitals to improve performance, according to Howard G. Phanstiel, president and chief executive officer of PacifiCare Health Systems.
   "We listened to consumers and employers who are demanding greater information concerning quality, service, and affordability at the hospital level and have responded with the industry's first report concerning hospital performance," said Phanstiel. "We believe that the QUALITY INDEX(R) profile of Hospitals is a significant step in the industry's pursuit of continuous quality improvement and accountability."

The Augusta Chronicle (Georgia)
March 3, 2003 Monday, ALL EDITIONS
TO STOP MEDICAL ERRORS, INDUSTRY MUST FIRST ADMIT THERE'S A PROBLEM
JESICA SANTILLAN passed the point of no return at precisely 4:50 p.m. on Feb. 7. This was the moment when the surgeon cut open the chest of the 17-year-old and removed her heart and lungs.
It's hard to overstate the drama of that moment in any heart transplant, let alone this one. After all, Jesica had been smuggled into this country from a small town in Mexico by parents intent on saving her life. She had waited three years at the gates of the "City of Medicine," as Durham, N.C., is pridefully labeled, for a new heart, new lungs and a new lease on life.

Newsweek
March 3, 2003, U.S. Edition
'A Tragic Error'
The calls began going out from Boston late on the evening of Thursday, Feb. 6, and continued well into the following morning. Somewhere in the six-state region covered by the New England Organ Bank a young person was dying, and the bureaucratic machinery devised to salvage life from death sprang into action. A coordinator entered the patient's vital statistics into the database maintained by the United Network for Organ Sharing (UNOS), which generated a ranked list of possible recipients for the useful organs. Hearts and lungs begin to deteriorate after just four to six hours outside the body, so the patients' location was one of the key factors the UNOS program considered, along with medical condition, body size and blood type. A heart in Miami may be useless in Seattle. A child's heart cannot keep a full-grown man alive.

The Atlanta Journal and Constitution
March 2, 2003 Sunday Home Edition
OUR OPINION: Girl's death may dim view of tort reform
In family snapshots, Jesica Santillan looks cheerful, upbeat, even healthy, underlining the tragedy of her death. The 17-year-old suffered from "restrictive cardiomyopathy," which enlarges the heart and weakens the lungs.
Jesica's one fragile hope for recovery --- a heart-lung transplant --- was doomed by an extraordinary mistake in the operating room at Duke University Medical Center. Surgeons performed a second transplant, but it was too late to save her. What must those days have been like for Jesica's family?

Knoxville News-Sentinel (Tennessee) March 2, 2003 Sunday Final Edition Transplant case stirs malpractice questions
Bill Frist, the only physician in the U.S. Senate, is hoping that his years of work to reform medical malpractice liability is not crushed by the death of 17-year-old botched transplant victim Jesica Santillan.
Frist said her death should not affect the proposal's chances of passage, but the public outcry over her death suggests there will be a long national debate on the issue before a majority agrees to certain liability limits.
Santillan died from complications in two transplant operations after she initially received a heart and lungs of the wrong blood type.

The Burlington Free Press (Burlington, VT)
February 28, 2003 Friday
Medical safety must be reformed
Jesica Santillan passed the point of no return at precisely 4:50 p.m. on Feb. 7. This was the moment when the surgeon cut open the chest of the 17-year-old and removed her heart and lungs.
It's hard to overstate the drama of that moment in any heart transplant, let alone this one. After all, Jesica had been smuggled into this country from a small town in Mexico by parents intent on saving her life. She had waited three years at the gates of the "City of Medicine," as Durham, N.C., is pridefully labeled, for a new heart, new lungs and a new lease on life.

Deseret News (Salt Lake City, Utah)
February 28, 2003, Friday
SECTION: OPINION; Pg. A12
Doctors must battle 'banality of screw-up'
BOSTON -- Jesica Santillan passed the point of no return at precisely 4:50 p.m. on Feb. 7. This was the moment when the surgeon cut open the chest of the 17-year-old and removed her heart and lungs.
It's hard to overstate the drama of that moment in any heart transplant, let alone this one. After all, Jesica had been smuggled into this country from a small town in Mexico by parents intent on saving her life. She had waited three years at the gates of the "City of Medicine," as Durham, N.C., is pridefully labeled, for a new heart, new lungs and a new lease on life.

The Times Union (Albany, NY)
February 28, 2003 Friday ONE STAR EDITION
Erring out our medical systems
Jesica Santillan passed the point of no return at precisely 4:50 p.m. on Feb. 7. This was the moment when the surgeon cut open the chest of the 17-year-old and removed her heart and lungs.
It's hard to overstate the drama of that moment in any heart transplant, let alone this one. After all, Jesica had been smuggled into this country from a small town in Mexico by parents intent on saving her life. She had waited three years at the gates of the "City of Medicine," as Durham, N.C., is pridefully labeled, for a new heart, new lungs and a new lease on life. But on that afternoon, all the surgical skill, all the training, all the high-tech machinery and experience at her service in the Duke University Medical Center was undone by a mistake as basic as the alphabet. Jesica, who had type O blood, was given organs from someone with type A.

Transplant News
February 28, 2003
Death of teenage transplant recipient due to blood type mix-up shines spotlight on medical errors; Jesica Santillan
     A Mexican teenager brought to the US by her parents in search of a life-saving heart-lung transplant died on February 22 because of a tragic mistake that resulted in her receiving organs with the wrong blood type.
    Despite heroic attempts to rectify the mistake with a second transplant, 17-year-Jesica Santillan died at the Duke University Medical School in Durham, NC.
    News of the mix-up ignited a media firestorm that included the vain effort to save Jesica with a second transplant, questions about US policy for transplanting foreign non-residents, and finally, on the great number of medical errors-44,000 to 98,000-- that occur in US hospitals every year.
    Duke pediatric transplant surgeon James Jaggers, MD, who had known Jesica for 2 years and performed the transplant, took full responsibility for accepting the mismatched organs.
    "As Jessica's surgeon, I had hoped that when we were offered organs from the donor service, that Jesica would be one of those lucky few-that we would prolong and improve her life with a heart-lung transplant," Jaggers said in a written statement. "Unfortunately, in this case human errors were made during the process. As Jesica's surgeon I am ultimately responsible for the team and for this error. I personally told the Santillan family about the errors that were made and then tried to do everything medically possible to treat Jesica and try to save her life."

The Baltimore Sun
February 27, 2003 Thursday FINAL Edition
Shining light on deadly problem of medical errors
BOSTON - Jesica Santillan passed the point of no return at precisely 4:50 p.m. on Feb. 7. This was the moment when the surgeon cut open the chest of the 17-year-old and removed her heart and lungs.
It's hard to overstate the drama of that moment in any heart transplant, let alone this one. After all, Jesica had been smuggled into this country from a small town in Mexico by parents intent on saving her life. She had waited three years at the gates of the "City of Medicine," as Durham, N.C., is pridefully labeled, for a new heart, new lungs and a new lease on life.

The Boston Globe
February 27, 2003, Thursday ,THIRD EDITION
ELLEN GOODMAN; SAFEGUARDING AGAINST MEDICAL ERRORS
JESICA SANTILLAN passed the point of no return at precisely 4:50 p.m. on Feb. 7. This was the moment when the surgeon cut open the chest of the 17-year-old and removed her heart and lungs.
It's hard to overstate the drama of that moment in any heart transplant, let alone this one. After all, Jesica had been smuggled into this country from a small town in Mexico by parents intent on saving her life. She had waited three years at the gates of the "City of Medicine," as Durham, N.C., is pridefully labeled, for a new heart, new lungs, and a new lease on life.

Charleston Daily Mail (West Virginia)
February 27, 2003, Thursday
It is human to make mistakes , It is necessary to install checks to prevent them

   BOSTON - Jesica Santillan passed the point of no return at precisely 4:50 p.m. on Feb. 7. This was the moment when the surgeon cut open the chest of the 17-year-old and removed her heart and lungs.
   It's hard to overstate the drama of that moment in any heart transplant, let alone this one.
   After all, Jesica had been smuggled into this country from a small town in Mexico by parents intent on saving her life. She had waited three years at the gates of the "City of Medicine," as Durham, N.C., is pridefully labeled, for a new heart, new lungs and a new lease on life.

FLORIDA TODAY (Brevard County, FL)
February 27, 2003 Thursday Final and all Editions
Learning from our many mistakes
    Learning from our many mistakes
   By Ellen Goodman
   Syndicated Columnist
   BOSTON -- Jesica Santillan passed the point of no return at precisely 4:50 p.m. on Feb. 7. This was the moment when the surgeon cut open the chest of the 17-year-old and removed her heart and lungs.
   It's hard to overstate the drama of that moment in any heart transplant, let alone this one. After all, Jesica had been smuggled into this country from a small town in Mexico by parents intent on saving her life. She had waited three years at the gates of the "City of Medicine," as Durham, N.C., is pridefully labeled, for a new heart, new lungs and a new lease on life.

Rochester Democrat and Chronicle
February 27, 2003 Thursday
Capping compensation will just hurt
    the victims of medical malpractice
   STEPHEN G. SCHWARZ
   GUEST ESSAYIST
   Kevin D. Hart's excellent Speaking Out essay (Feb. 4) on the latest crisis in medical malpractice premiums supports what judges and trial lawyers have known for years: These periodic spikes in the rates doctors pay for their insurance have virtually nothing to do with the legal system.
   Historically, however, politicians seek to diminish the rights of malpractice victims whenever one of these "crises" hit, and President Bush has now advanced a plan to follow that dubious precedent.
   As a Wall Street Journal article of June 24, 2002, clearly documented, this latest "crisis" is again of the insurance industry's own making. In the boom years of the '90s, the industry took in billions of dollars in premiums, invested them in the stock market and produced billions more in profits. Many companies cut prices, insured questionable risks (i.e. repeat malpractice offenders) and entered markets they knew little or nothing about. Like so many others, the insurance industry focused only on the short term. Now, after several years of stock value declines, the piper must be paid.

Chicago Tribune
February 26, 2003 Wednesday, NORTH SPORTS FINAL EDITION
Self-healing would help doctors' cause
Thomas Pliura has an idea that goes beyond the doctors' protest he has organized Wednesday in Springfield.
That's Thomas Pliura, M.D. And Thomas Pliura, Esq.

Highlands Today
February 26, 2003
Highlands Doctors To Attend Rally; They Want Malpractice Relief But Lawyers Say Medical Errors Kill
    SEBR1NG--Physicians who say they are sick of lawyers whose huge contingency fees are putting them out of business are going to demand Florida lawmakers put a stop to it.
   They plan to "Rally at the Capitol" on March 27.
   When they do, physicians, their families and their staff members will cheer on lawmakers to put a lid on the amount of money juries can award to victims for the pain and suffering doctors cause them.
   They say the law is needed, not merely to stop the rise in medical malpractice insurance premiums, but to reduce them to a level that allows the doctors to make money.
   The penally if lawmakers fail is that doctors and hospitals will eliminate services or even move away to states that are more receptive to their financial health.

The Washington Post
February 26, 2003, Wednesday, Final Edition
Medical Checks and Balances

THE SURGEON WHO performed poor Jesica Santillan's botched transplant has already taken the blame. "I am ultimately responsible," Dr. James Jaggers of Duke University Hospital said in a statement. Thus he's become a figure both noble and detestable, the captain of a sunk ship, a confirmation that Americans mythologize doctors while deeply suspecting them of the capacity for great arrogance and harm.

The Post-Standard (Syracuse, NY) February 25, 2003 Tuesday Final Edition LESSONS FROM SORROW; THE CASE OF JESICA SANTILLAN SHOULD PROD IMPORTANT DISCUSSIONS
The nation watched in horror and sadness as the story of Jesica Santillan moved toward its unhappy end at Duke University Medical Center. While drawing cosmic conclusions from extraordinary situations can be unwise, the case offers a starting point for discussions on a couple of important national issues: the availability of organs for transplant and the frequency of deadly medical errors.
The 17-year-old girl died Saturday after undergoing a second heart-lung transplant on Thursday. In the first operation, performed Feb. 7, she was given a heart and lungs from a donor with the wrong blood type. Her body rejected the organs, and she was near death before a donor of the correct blood type was found. The second set of organs worked, but Santillan died from bleeding in the brain.

The Stanford Daily via U-Wire University Wire
February 25, 2003, Tuesday
An ethical prescription
Doctors at Duke University Hospital delivered grim news on Saturday: Jesica Santillan -- an optimistic 17-year-old who only a few days ago believed she would receive a lifesaving transplant -- had died. Santillan was the unfortunate victim of a medical mishap in which she received a heart and lung transplant of the wrong blood type and then had to undergo a second transplant, which proved to be unsuccessful.
Her death is a reminder that even practitioners of one of the most highly esteemed professions, medicine, can make irreversible mistakes. Doctors that make such mistakes are not entirely at fault. Today, most physicians are overworked and face intense pressure from a demanding health care system. Even the most caring practitioners can make an error.

Business Insurance
February 24, 2003, Monday
Med mal reform is bad medicine
    Linda McDougal, the Wisconsin woman whose doctor mistakenly performed a double mastectomy on her even though she was cancer-free, has decided to become the poster child against medical malpractice tort reform.
   At the risk of sounding like a liberal, I'm with her.
   The tort system's fundamental moral purpose is to punish those who harm others, and, where feasible, to force them to pay restitution to their victims. Capping doctors' malpractice liability for noneconomic damages at $250,000-which is less than one year's salary for most of them-effectively removes the deterrent the tort system is meant to create.

Managed Care Weekly Digest
DATE1: February 24, 2003
February 24, 2003
MEDICAL ERRORS: Patients hurt even after hospital release, study finds
Patients are often harmed by inadequate care and outright medical mistakes in the days after they are sent home from the hospital, according to new research.
The study, conducted at one large hospital, found that nearly one in five patients had "adverse events" after they went home - new or worsening symptoms resulting from the treatment they received, not from their underlying disease. Most problems could have been prevented or eased with better care.

Desert News (Salt Lake City, Utah)
February 23, 2003, Sunday
SECTION: WIRE; Pg. A02
Elite hospitals have share of lapses, too
The medical error that led surgeons to put the wrong organs into a teenager at Duke University Hospital on Feb. 7 was not the first embarrassment in recent years for this elite medical institution. Nor are such problems limited to Duke.
In 1999, federal officials suspended the hospital's license to conduct all of the university's clinical trials and other human experiments for four days because it had violated ethics and safety rules, did not fully warn volunteers of risks and had lax record-keeping for clinical trials.

The New York Times
February 23, 2003, Sunday, Late Edition - Final
Even the Elite Hospitals Aren't Immune to Errors
The medical error that led surgeons to put the wrong organs into a teenager at Duke University Hospital on Feb. 7 was not the first embarrassment in recent years for this elite medical institution. Nor are such problems limited to Duke.
In 1999, federal officials suspended the hospital's license to conduct all of the university's clinical trials and other human experiments for four days because it had violated ethics and safety rules, did not fully warn volunteers of risks and had lax record-keeping for clinical trials.

Berhad New Straits Times (Malaysia)
February 23, 2003, Sunday
Medical negligence cases on the rise
    JACK'S mother died of a second heart attack five hours after the doctor failed to diagnose the first one.
   This, despite him telling the doctor that another doctor, who had attended to his mother after she collapsed, had said she could have suffered a heart attack.
   Can the second doctor be charged with negligence for failing to detect the first attack and allowing Jack's mother to be sent home?
   Recent news that Malaysia's medical negligence rate had reached 40 per cent sent ripples through the medico-legal community.
   Could it possibly be that for every 100 patients treated, 40 were treated negligently?

The Baltimore Sun
February 21, 2003 Friday FINAL Edition
Reforms for patient safety listed as critical; 'Very little has been done' to prevent medical errors
    For all the focus on reducing medical errors in recent years, the cultural changes that institutions must make to keep patients safe have been slow to develop.
   The gravity of the problem was highlighted this week in the case of a 17-year-old girl who was given a heart and lungs from an organ donor of the wrong blood type at Duke University Hospital.
   More than three years after the Institute of Medicine released a headline-grabbing report on the frequency of errors and a plan for reducing them, some medical experts say progress has been limited.
   "It galvanized public awareness for safety, but the reality is actually very little has been done nationally to improve safety since then," said Dr. Peter J. Pronovost, co-chairman of the Patient Safety Committee at Johns Hopkins Hospital. "Now we're aware, but now we've got to act."

The Record (Bergen County, NJ)
February 21, 2003 Friday All Editions
Transplant error can be prevented
    JESICA SANTILLAN was recently the victim of a medical error. Jesica was expected to die within six months without a heart and lung transplant.
   She was listed for a transplant at the Duke University Hospital in Durham, N.C. But her prospects were not good due in part to the shortage of donor organs, and in part to a horribly unfair design in nature: People with type O blood can donate blood and organs to people of all other blood types, but they can only receive blood and organs from people with their own blood type.
   Then the miraculous seemed to happen: the New England Organ Bank contacted Carolina Donor Services offering a heart and lungs. Duke University Hospital accepted these organs and, while they were being flown to Carolina, began the transplant process with Jesica. She was prepared for surgery, her own heart and lungs were removed, and when the donor organs arrived, they were implanted.

National Journal's CongressDaily
February 13, 2003 Thursday 10:30 am Eastern Time am SECTION: HEALTH
House Panel OKs Medical Error Bill
The House Energy and Commerce Committee approved a bill Wednesday to create a network of federally-chartered medical-error data banks that would collect confidential information from hospitals, nursing homes, physicians, nurses and others in an effort to reduce deaths and injuries caused by medical mistakes.
Action came on a voice vote with no debate.

The Gleaner
February 12, 2003
FT-ACC-NO: A20030212182-3C94-GNW
CHILDREN'S CORNER

   Children & domestic violence
   sThe spectrum of abuses faced by children in the family or community, according to a 2002 report published by the World Federation for Mental Health, ranges from ill treatment in institutions to violence in the family, from child trafficking to child bonded labour.
   The report states that the vulnerability of children to such abuses often depends on other aspects of their identity, such as gender, ethnicity or economic status. This is a powerful reminder of the indivisibility of human rights. The dpenial of one set of rights leads to the abuse of others.
   Research has demonstrated repeatedly that the impact of domestic and community violence on child development is devastating. Some key findings:
   * Even infants and toddlers are gravely affected. Studies show that infants and toddlers who witness either violence in the community or in the home show excessive irritability, immature behaviour, sleep disturbances, emotional distress, fear of being alone and regression intoileting and language. Exposure also interferes with the normal tendency toddlers have to explore their environment. Some studies even have noticed symptoms in toddlers that may indicate post-traumatic stress disorder.

Reno Gazette-Journal
February 11, 2003 Tuesday
Keeping medicine safe for children
    By Jason Hidalgo
   RENO GAZETTE-JOURNAL
   Siren sounds and make-believe emergency dispatch fill the air in Robert and Sherry Mason's Reno home as their 2-year-old son, Logan, backs the toy fire truck he's riding into a pile of toys.
   Smiling from ear to ear, Logan gets off and picks up a wrapper on the floor. Sherry Mason says, "ooh, that's ucky," and asks Logan to get rid of it. He places the wrapper in his shirt pocket instead, then pounces on his dad's lap.
   "It's amazing what we find in the wash," said Robert Mason, noting his son's propensity for keeping stuff in his pockets. "Last time I found a lima bean, a penny and a Band-Aid."

Medical Post February 11, 2003 Better measurement needed to stop med errors: as many as 98,000 U.S. patients die annually due to preventable errors
TORONTO - To reduce medical errors, efforts must focus on better measurement of the problem, finding new tools and strategies for change, and improving the context in which care is given to prevent and intercept errors, according to Dr. Ross Baker (PhD).
Dr. Baker, an associate professor of health policy, management and evaluation at the University of Toronto, is leading a study looking at adverse events in Canadian hospitals. He spoke to delegates at a physician session on patient safety at the recent Ontario Hospital Association convention.
Evidence of unacceptable levels of adverse events in health care has emerged from the U.S., Australia, Britain, France, Denmark and New Zealand. The Quality in Australian Health Care Study, one of the first to explore the issue, found 16% of admissions were associated with adverse events.

Baseline.com February 10, 2003 Monday Hospital Revives Its "Dead" Patients; 8,500 people at St. Mary's Mercy thought they were still alive. But the hospital's computers were telling them they were not.
In October, Cathy Uhl gave a blood sample as part of a routine physical examination, but less than two months later--according to the hospital that processed her laboratory results--she was dead.
Fortunately, Uhl and some 8,500 other patients who received treatment at St. Mary's Mercy Medical Center in Grand Rapids, Mich., between Oct. 25 and Dec. 11 were able to read of their unfortunate "demise" in the bills sent out by the hospital's flawed patient management software system.
"You could say I was a little surprised," Uhl says. "I was pretty sure I wasn't dead, but you never know. The hospital explained it was just a computer glitch, but I'm still waiting to see what this is going to mean for me."

Chicago Tribune
February 7, 2003 Friday, NORTH SPORTS FINAL EDITION
Solving the malpractice mess
Last month, more than two dozen surgeons in four West Virginia hospitals walked out to protest rocketing malpractice insurance rates. One doctor, a general surgeon, said he had to borrow money to pay a $73,000 insurance bill, and added that he was considering leaving the state if his premiums don't abate.
The protest has spread in recent days, with doctors in Illinois, New Jersey, Florida and Mississippi walking out or threatening to take such action. President Bush has joined the battle, promising he will propose reforms to clamp down on jury awards and control malpractice premiums. One highlight: a $250,000 cap on non-economic damages such as "pain and suffering" awards.

Creative Loafing Atlanta
DATE1: February 5, 2003
DATE2: February 11, 2003
February 5, 2003 - February 11, 2003
Justice in Peril
    On Nov. 26, 1996, Mary Wilson and her husband Don walked into Candler Hospital in Savannah to have a baby. Mary Wilson was 39 years old, and by virtue of her age, considered a high-risk pregnancy.
   Up to that point, everything about the child she had been carrying for the previous nine months had been normal. Two years earlier, Wilson had delivered a 9-pound, 3-ounce boy, Justin, by Caesarean section. She was forced to have the operation because the baby's head was too large for a vaginal birth.
   An ultrasound indicated that the baby in her belly, Christopher, would also be a large child, more than 8 pounds. Because of the weakness a C-section causes in the uterine wall, doctors often recommend subsequent children also be delivered by C-section to decrease the likelihood of rupturing the uterus. Wilson's obstetrician, though, told her they would try natural childbirth. He claimed it was for insurance purposes and better for the baby. She agreed.

Guelph Mercury (Ontario, Canada)
February 4, 2003 Tuesday Final Edition
Journal study: Patients hurt by medical errors after discharge
Patients are often harmed by inadequate care and outright medical mistakes in the days after they are sent home from the hospital, a study finds.
The study, conducted at one large hospital, found that nearly one in five patients had "adverse events" after they were sent home -- new or worsening symptoms resulting from the treatment they received, not from their underlying disease. Most of the problems could have been prevented or eased with better care.

The Record (Kitchener-Waterloo, Ontario)
February 4, 2003 Tuesday Final Edition
Patient relapse rate 'not surprising' due to lack of follow-up
Patients are often harmed by inadequate care and outright medical mistakes in the days after they are sent home from the hospital, a study finds.
The study, conducted at one large hospital, found nearly one in five patients had "adverse events" after they were sent home -- new or worsening symptoms resulting from the treatment they received, not from their underlying disease. Most of the problems could have been prevented or eased with better care.

St. Louis Post-Dispatch (Missouri)
February 4, 2003 Tuesday Five Star Late Lift Edition
TAKING THE CURE
    MALPRACTICE INSURANCE, PART II
   GIVEN their druthers, doctors would try to cure their malpractice insurance ills by performing a lawyer-ectomy. Sedate the greedy lawyers, surgically insert a cap on lawsuits, and society would live happily ever after, or so say the doctors.
   They have the wrong diagnosis. To cure the malpractice insurance mess, we'd have to shoot some adrenaline into Wall Street.

Albuquerque Journal (New Mexico)
February 3, 2003 Monday
Researcher questions fatal error rate
    * New study with hospitalized children rekindles debate on earlier report
   Six out of 100 hospitalized children suffer problems from prescribed drugs, whether through errors or side effects of properly administered medications, according to a study led by an Albuquerque pharmacist.
   The research, published last month in the Archives of Pediatric and Adolescent Medicine, confirms that "adverse drug events," already shown to be common among hospitalized adults, also occur among children.
   But the study did yield some unexpected results, according to Mark Holdsworth, associate professor of pharmacy and pediatrics at the University of New Mexico. Those medication problems didn't seem to play a major role in children's survival or length of time spent in the hospital.

Baseline
February 1, 2003 Saturday
St. Mary's Scare;
8,500 patients at a Michigan hospital thought they were still alive. But its computers were telling them they were not.
In October, Cathy Uhl gave a blood sample as part of a routine physical examination, but less than two months later according to the hospital that processed her laboratory results she was dead.
Fortunately, Uhl and some 8,500 other patients who received treatment at St. Mary's Mercy Medical Center in Grand Rapids, Mich., between Oct. 25 and Dec. 11 were able to read of their unfortunate "demise" in the bills sent out by the hospital's flawed patient management software system.
"You could say I was a little surprised," Uhl says. "I was pretty sure I wasn't dead, but you never know. The hospital explained it was just a computer glitch, but I'm still waiting to see what this is going to mean for me."

Florida Underwriters
February 2003
Consumers' Position
    Consumer advocates are firing back at the medical and insurance industry lobbies, challenging them to stop blaming rising malpractice rates on consumer remedies in the courtroom.
   "Doctors are falsely demonizing America's legal system rather than saving tens of thousands of lives and litigation costs by preventing careless or unnecessary medical errors, such as operating on the wrong part of the body," said Joan Claybrook, president of Public Citizen.
   Opponents of malpractice caps say:
   * Just 5.1 percent of doctors account for 54.2 percent of the malpractice payouts. Of the 35,000 doctors who have had two or more malpractice payouts since 1990, only 7.6 percent of them have been disciplined. And only 13 percent of doctors with five medical malpractice payouts have been disciplined.

HealthFacts
February 1, 2003
Malpractice is the problem not the high cost of malpractice insurance.
We are in the grip of a malpractice insurance crisis because doctors have threatened to strike, relocate, stop performing risky procedures, or increase their patient load. If you believe the media reports, the cause is "skyrocketing insurance premiums." Pregnant women are unable to find an obstetrician, and some areas of the country will be left without any surgeons. The cost of insurance premiums is rising, we are told, as a result of astronomical malpractice awards, many of them frivolous. The only solution is to put a cap on these awards. The double-digit health insurance inflation will be controlled once state legislators and Congress pass laws putting limits on awards for pain and suffering.
That's pretty much the scenario conveyed by the media whenever a malpractice insurance crisis resurfaces every five to ten years. Somehow the crucial issue of malpractice itself and ways to reduce injuries to patients rarely seem to enter the story. The crisis is always going to be solved by limiting the amount of money the injured person can receive. This is what passes for tort reform. Yet the last time a major study looked at malpractice, it found that the majority of people who were victims of malpractice did not sue, and of those who did go to trial, most lost their cases.

Healthcare Financial Management
February 1, 2003
Establishing ROI for technology to reduce medication errors is both a science and an art; The Business Case for Medication Safety; return on investment
     Fact: Preventable medical errors result in 44,000 to 98,000 deaths among hospital patients each year--more than die from workplace accidents, motor-vehicle wrecks, breast cancer, and AIDS
    Fact: Medication errors alone cause an estimated 7,000 deaths every year.
    Fact: These medication errors cost the nation $ 2 billion in terms of lost income, lost household production, disability, and healthcare cost.
    These statistics rocked the healthcare industry and the Public when the Institute of Medicine (IOM) released its landmark report To Err Is Human: Building a Safer Health System in 1999.
    Even without the mounting pressure on hospitals from the Joint Commission on Accreditation of Healthcare Organizations, the IOM, and purchaser consortiums such as the Leapfrog Group to employ patient-safety information technology (IT), health care is experiencing rising public expectations as more people employ technology in other aspects of their lives outside of health care. Increasingly, consumers also are learning about advances in healthcare technology that may not be available in their local areas. As a result, some organizations may soon need to catch up to their competitors to retain service-line market share.

Ledger (Lakeland, Florida)
February 1, 2003, Saturday
REDUCING FATAL MEDICAL ERRORS; EDITORIAL

   When musician Maurice Gibb died at a Miami Beach hospital earlier this month, the family raised questions about the quality of care.
   "We believe mistakes were made," his brothers told the British Broadcasting Corp. "We will pursue that relentlessly. That will be our quest from now on."
   Did a medical error cause Gibb's death? It would not be altogether surprising.

Business Wire
January 30, 2003, Thursday
Educational Program Significantly Reduces Medical Errors; Studies Reported at Society of Critical Care Medicine's 32nd Critical Care Congress

   Identifying areas of weakness and then educating medical personnel on those topics can improve patient safety, according to two studies released today at the 32nd Critical Care Congress of the Society of Critical Care Medicine.
   Fiona H. Levy, MD, medical director of the pediatric intensive care unit (ICU) and medical director of quality management at St. Louis Children's Hospital, reports that after conducting a mandatory seminar on mechanical ventilation, significant improvements were found in ICU performance and patient safety-and those improvements continued for at least six months.
   "The study results were reassuring and affirming. We were able to decrease ventilator-associated medical errors by identifying mechanical ventilation as a weakness and designing a ventilator education and communications seminar for ICU nurses and respiratory therapists," she says.

Business Wire
January 30, 2003, Thursday
Educational Program Significantly Reduces Medical Errors; Studies Reported at the Society of Critical Care Medicine's 32nd Critical Care Congress

   Identifying areas of weakness and then educating medical personnel on those topics can improve patient safety, according to two studies released today at the 32nd Critical Care Congress of the Society of Critical Care Medicine.
   Fiona H. Levy, MD, medical director of the pediatric intensive care unit (ICU) and medical director of quality management at St. Louis Children's Hospital, reports that after conducting a mandatory seminar on mechanical ventilation, significant improvements were found in ICU performance and patient safety--and those improvements continued for at least six months.
   "The study results were reassuring and affirming. We were able to decrease ventilator-associated medical errors by identifying mechanical ventilation as a weakness and designing a ventilator education and communications seminar for ICU nurses and respiratory therapists," she says.

U.S. Newswire
January 30, 2003 Thursday
Education Program Reduces Medical Errors: Studies Reported at Society of Critical Care Medicine's 32nd Critical Care Congress
LEAD: Identifying areas of weakness and then educating medical personnel on those topics can improve patient safety, according to two studies released today at the 32nd Critical Care Congress of the Society of Critical Care Medicine. Fiona H. Levy, MD, medical director of the pediatric intensive care unit (ICU) and medical director of quality management at St. Louis Children's Hospital, reports that after conducting a mandatory seminar on mechanical ventilation, significant improvements were found in ICU performance and patient safety-and those improvements continued for at least six months.
"The study results were reassuring and affirming. We were able to decrease ventilator-associated medical errors by identifying mechanical ventilation as a weakness and designing a ventilator education and communications seminar for ICU nurses and respiratory therapists," she says.

Chicago Tribune
January 29, 2003 Wednesday, NORTH SPORTS FINAL EDITION
Gender bias seen in malpractice cases
President Bush believes a $250,000 cap on medical malpractice awards for the pain and suffering associated with doctors' errors will help curtail spiraling health-care costs.
But since he unveiled his prescription for tort reform, critics have been lining up, especially women, who say caps on jury awards will result in gender discrimination in malpractice cases and might end up keeping defective and dangerous drugs and medical devices made for women in the marketplace.

PR Newswire
January 28, 2003, Tuesday
Texas Patient Safety Foundation Joins Malpractice Fight on Consumers' Side; New Web Site to Collect Information About Doctors and Hospitals Named In Lawsuits and Make It Available to the Public
The following press release is being issued by the Texas Patient Safety Foundation: A Dallas family that has been devastated by the loss of a family member through a physician's error has established a foundation to help Texas consumers find information about incidents of medical malpractice and report them. Carol Barger, a Dallas resident who served on the Texas Board of Medical Examiners (TBME) as a consumer representative, has agreed to serve as an advisor to the foundation, announced Craig Franklin, head of the new Texas Patient Safety Foundation. Among the foundation's top priorities will be monitoring the TBME's performance, Franklin said. The foundation's web site, www.TexasPatientSafetyFoundation.org , will collect information about doctors and hospitals named in lawsuits involving serious death and injury and make this information available to the public. Until now, no such clearinghouse has existed for this type of information, which consumers may want to consider before selecting a physician or a hospital, Franklin said. Franklin, whose 62-year-old mother died in December 2000 after a doctor forgot to re-start her ventilator during a routine gallbladder surgery, said that the Texas Patient Safety Foundation also will be a voice for consumers, as lawmakers take up the issue of medical malpractice this session. "We cannot be silent while an estimated 3,300 to 7,200 patients die in Texas every year as the result of preventable medical errors," said Franklin, a Dallas-area business consultant. Franklin said that he and other family members will meet with Dallas-area lawmakers in Austin on Wednesday to voice concern about a bill circulating in the Legislature to curtail the public's access to information about complaints against doctors.

Columbus Dispatch (Ohio)
January 24, 2003 Friday, Home Final Edition
MEDICAL-ERROR STATISTICS INTERPRETED POORLY
I respond to the Jan. 16 Associated Press article in The Dispatch "Surgical tools left in 1,500 patients a year, study says."
The article reports that the study was done by checking "insurance records from about 800,000 operations in Massachusetts for 16 years ending in 2001." It goes on to say that "they calculated a national estimate of 1,500 cases yearly." This reporting is very representative of the mistake made not only by reporters in the popular media but even medical researchers who should know better.

The International Herald Tribune
January 24, 2003 Friday
LETTERS TO THE EDITOR; Medical malpractice
Regarding the editorial "When doctors make mistakes" (Jan. 18):
It would be a travesty of justice for Congress and state legislatures to take away patients' legal rights in the name of protecting insurance company profits and doctors' income. Doctors should be calling on medical boards to better police their own and demanding reform of the insurance industry.

Newsday (New York)
January 24, 2003 Friday NASSAU AND SUFFOLK EDITION
Bush Malpractice Plan Is Very Bad Medicine
    If you want to know what's wrong about President George W. Bush's medical malpractice reform plan, just look at the case of Linda McDougal.
   In May 2002, McDougal was diagnosed with breast cancer.
   A biopsy revealed a malignancy so aggressive that her only hope for survival was a double mastectomy, followed by chemotherapy and radiation.
   Two days after the surgery, however, McDougal's doctor delivered the horrible news - she didn't have cancer after all. The laboratory had mixed up the tissue samples, giving McDougal another woman's results. Two physicians had failed to check her name against the test records before scheduling the operation. It was every patient's nightmare. Her two healthy breasts had been amputated because of a pathologist's mistake.

Star Tribune (Minneapolis, MN)
January 24, 2003, Friday, Metro Edition
Victims of medical error testify on Capitol Hill; A Wisconsin woman whose breasts were needlessly removed is urging Congress to reject limits on jury awards.
    Linda McDougal, whose breasts were removed in an unnecessary surgery at a St. Paul hospital, came to Capitol Hill on Thursday to say that President Bush "intends to harm me and other victims" by seeking to put a $250,000 limit on jury awards for victims of medical errors.
      "I have lived with the horror of this for over 7 1/2 months . . . I will never have what I had before," McDougal said at a news conference.
      McDougal, who went public with her story last week, has found allies in Washington. They include the Association of Trial Lawyers of America and the Center for Justice and Democracy, two groups that are publicizing her case as they fight the president's plan.

Chicago Tribune
January 22, 2003 Wednesday, NORTH SPORTS FINAL EDITION
Medical malpractice at a discount; When the loss of happiness and fulfillment is worth practically nothing
If you want to know what's wrong about President Bush's medical malpractice reform plan, just look at the case of Linda McDougal. In May 2002, McDougal was diagnosed with breast cancer. A biopsy revealed a malignancy so aggressive that her only hope for survival was a double mastectomy, followed by chemotherapy and radiation. Two days after the surgery, however, McDougal's doctor delivered the bad news--she didn't have cancer after all. The laboratory had mixed up the tissue samples, giving McDougal another woman's results, and two physicians had failed to check her name against the test records before scheduling the operation. In every patient's nightmare, her two healthy breasts had been amputated because of a pathologist's mistake.
Under President Bush's proposal, McDougal's ability to sue for malpractice would be drastically limited, primarily to her so-called "economic losses." In this case, that means she would not have to pay for the needless mastectomies or the egregious lab work, she would be reimbursed for reconstructive surgery, she would receive her lost wages (if any) during recovery and she would be entitled to a lifetime supply of prosthetic bras.

Creative Loafing Atlanta
DATE1: January 22, 2003
DATE2: January 28, 2003
January 22, 2003 - January 28, 2003
Let's Reform Tarts, Not Torts
    What's all of this fuss I hear about tart reform? Simply ridiculous, I say. How in the world can we expect the Georgia Assembly to reform all the brazen little tarts in this state?
   Still, tart reform must be a good idea since it's being pushed by the Georgia Chamber of Commerce. That sure surprised me. I sorta thought the chamber liked tarts-- after all, those escort babes really help pump (so to speak) cash into the convention and tourism biz.
   But now just about every lovin' soul wants tart reform. Gubner Sonny "Just Call Me Big Buddy" Perdue wants fewer tarts around. Senate President Pro Tem Eric Johnson says ditto. Shucks, just about everyone is against tarts except for lawyers, and I'm not one bit surprised to find them in bed (ahem!) with battalions of trollops.

CNN
SHOW: CNN WOLF BLITZER REPORTS 17:00
January 20, 2003 Monday
Hussein Resting Easy Despite Military Buildup
LEAD: (BEGIN VIDEOTAPE)   WOLF BLITZER, CNN ANCHOR (voice-over): To those U.N. weapons inspectors and allies who still say they need months to determine whether the Iraqis have weapons of mass destruction, Defense Secretary Donald Rumsfeld pointedly offered this.
   DONALD RUMSFELD, DEFENSE SECRETARY: Either they will cooperate or they won't and it will not take months to determine whether or not they are cooperating.
   BLITZER: That would suggest the showdown with Iraq, if the Bush administration has its way, could play out within weeks.
   In one week, U.N. inspectors Hans Blix and Mohamed ElBaradei will report to the Security Council on what they found. In advance of that report, Secretary of State Colin Powell spent the day at the United Nations trying to enlist support for the tough U.S. stance.

CNN
SHOW: CNN CONNIE CHUNG TONIGHT 20:00
January 20, 2003 Monday
Nightmarish Medical Mix-Up; Murder by Mercedes or Accident?
LEAD: CONNIE CHUNG, HOST: Good evening. I'm Connie Chung.   Tonight: a nightmarish medical mixup: radical surgery on a patient for a disease she didn't have.
   (BEGIN VIDEO CLIP)
   LINDA MCDOUGAL, UNDERWENT MISTAKEN DOUBLE MASTECTOMY: I have a story that I think is important to a lot other women out there.
   (END VIDEO CLIP)
   ANNOUNCER: A horrifying medical mistake.

St. Petersburg Times (Florida)
January 19, 2003 Sunday
Quack remedy to cap malpractice awards
    If President Bush had read the front pages Thursday, he would have seen the story, first reported by the New England Journal of Medicine, that said surgical teams leave clamps, sponges and other potentially lethal things in about 1,500 people a year.
   But he must have stopped at the sports page, or maybe the crossword puzzle. In a speech later that day, he came out hard, again, for a quack cure for the medical malpractice problem.
   As he seems to see it, the problem is simply that too many people are suing too many doctors for too much money. So he wants to cap "pain and suffering" awards at $250,000, and to crack down on lawyers' fees, too.

The Asheville Citizen-Times
January 18, 2003 Saturday Final Edition
Physicians, insurers mislead public about medical malpractice 'crisis'
    Physicians, insurers mislead public about medical malpractice 'crisis'
   Editor's note: This guest commentary was printed in the AC-T previously, but was attributed to the wrong author.
   By Thomas Coulson
   Years ago, Joseph Califano, former Secretary of Health Education and Welfare, was quoted as saying that health care finance was a shell game where each segment of the industry did its best to hide its share of the cost under someone else's shell.
   Of course, operating a real shell game can land you in jail for fraud, but for politicians, public relations folks and corporate leaders, the laws on fraud don't seem to apply.
   There exists no better example of this than the regularly recurring medical malpractice "crisis."

Austin American-Statesman (Texas)
January 17, 2003, Friday
SECTION: News; Pg. A1
Critics: Insurance crisis symptoms don't fit cure They say statistics undercut legislators' belief that frivolous suits inflate doctors' premiums
    The fever that began rising from insurance company spreadsheets about two years ago incubated during last year's elections and gripped many of the state's politicians on the campaign trail.
   Now, Gov. Rick Perry and many top lawmakers are consumed by the belief that greedy lawyers and rapacious juries are ruining the Texas health care system. The best way to stop it, those who have caught reform fever say, is by making it harder for patients to sue their doctors.
   The zeal to rein in medical malpractice lawsuits in Texas is a carbon copy of President Bush's efforts at the national level. On Thursday, Bush called on Congress to enact national limits on jury awards in medical malpractice cases.

Austin American-Statesman (Texas)
January 17, 2003, Friday
SECTION: News; Pg. A1
In malpractice crisis, a second opinion emerges Critics: Evidence undercuts politicians' belief that frivolous suits are behind rising premiums
    The fever that began rising from insurance company spreadsheets about two years ago incubated during last year's elections and gripped many of the state's politicians on the campaign trail.
   Now, Gov. Rick Perry and many top lawmakers are consumed by the belief that greedy lawyers and rapacious juries are ruining the Texas health care system. The best way to stop it, those who have caught reform fever say, is by making it harder for patients to sue their doctors.
   The zeal to rein in medical malpractice lawsuits in Texas is a carbon copy of President Bush's efforts at the national level. On Thursday, Bush called on Congress to enact national limits on jury awards in medical malpractice cases.

Cox News Service
January 17, 2003 Friday
More than one cure for medical insurance crisis
    The fever that began rising from insurance company spreadsheets about two years ago incubated during last year's elections and gripped many of the state's politicians on the campaign trail.
   Now, Gov. Rick Perry and many top lawmakers are consumed by the belief that greedy lawyers and rapacious juries are ruining the Texas health care system. The best way to stop it, those who have caught reform fever say, is by making it harder for patients to sue their doctors.
   The zeal to rein in medical malpractice lawsuits in Texas is a carbon copy of President Bush's efforts at the national level. On Thursday, Bush announced his plan to curb litigation as the best solution for an insurance crisis that is roiling the country.

MSNBC
SHOW: THE ABRAMS REPORT 18:00 January 16, 2003 Thursday THE ABRAMS REPORT For January 16, 2003
DAN ABRAMS, HOST: On the agenda tonight: Iraq says it forgot about weapons found today by inspectors that could hold chemical weapons. Is this the evidence that could lead to war?
Then:
(BEGIN VIDEO CLIP)
ROBERT BLAKE, DEFENDANT: If I am going to die in the box, I want to talk before I go. I want Rosie to know who her daddy is.
(END VIDEO CLIP)
ABRAMS: It could be his best performance in years. Former "Baretta" star Robert Blake goes on a tearful rant before a camera in jail. We'll talk to the lawyer who witnessed the bizarre tirade.

The Asheville Citizen-Times
January 15, 2003 Wednesday Final Edition
On malpractice 'crisis,' physicians, insurers playing a shell game
    On malpractice 'crisis,' physicians, insurers playing a shell game
   Years ago Joseph Califano, former Secretary of Health Education and Welfare, was quoted as saying that health care finance was a shell game where each segment of the industry did its best to hide its share of the cost under someone else's shell. Of course, operating a real shell game can land you in jail for fraud, but for politicians, public relations folks and corporate leaders, the laws on fraud don't seem to apply. There exists no better example of this than the regularly recurring medical malpractice "crisis."
   As the New Year begins, surgeons in West Virginia are striking (actually, they're on "leaves of absence," strikes being so lower- class, not to mention illegal). They're demanding that something be done about malpractice premiums, preferably by restricting the rights of citizens to sue. Next door in Pennsylvania, doctors were threatening to leave the state en masse because of escalating malpractice premiums, until Gov.-Elect Randell agreed to push his cash-strapped legislature for millions in assistance to underwrite their insurance. Further south, in Texas, the legislature is poised to pass tort reform capping damages and further impairing the rights of citizens to seek redress for malpractice.

The Tennessean
January 14, 2003 Tuesday 1st Edition
HEALING WORDS
    Ignoring medical errors would be a big mistake
   By DR. FRANK BOEHM
   America's health-care system is in crisis.
   From large numbers of uninsured citizens, to spiraling health- care costs, problems are everywhere. Doctors are burdened with malpractice insurance premiums that in many cases are forcing them to retire or leave their practices, and hospitals cannot find enough nurses to keep units open, much less provide adequate care to patients.

The Tennessean
January 14, 2003 Tuesday 1st Edition
Ignoring medical errors would be a big mistake
    America's health-care system is in crisis.
   From large numbers of uninsured citizens, to spiraling health- care costs, problems are everywhere. Doctors are burdened with malpractice insurance premiums that in many cases are forcing them to retire or leave their practices, and hospitals cannot find enough nurses to keep units open, much less provide adequate care to patients.
   Added to these problems is a real concern about patient safety. In the late 1990s, responding to a series of highly publicized errors, the American Medical Association, along with other physician organizations, joined consumer groups to form the National Patient Safety Foundation, which performs research, educates and lobbies Congress on issues related to patient safety.

Ledger (Lakeland, Florida)
January 13, 2003, Monday
MEDICAL CRISIS MAY STIR REFORMS

   WASHINGTON -- Lindell Orr wrote two recommendations last week for area obstetricians fleeing the state of Florida for Texas and Louisiana, where medical malpractice insurance is cheaper.
   "I'm seeing doctors quit practicing at 55," the chief of Doctors Hospital of Sarasota said. "It's really sad.
   The hospital closed its obstetrics unit last month, adding pressure to surrounding hospitals such as Sarasota Memorial that still deliver babies. But Sarasota Memorial has had trouble covering emergency-room specialists such as neurologists and gastroenterologists, and officials there worry obstetrics might be next.

Morning Star (Wilmington, NC)
January 13, 2003, Monday
Lawyers, Edwards on trial; Demands to cap malpractice costs put him in spotlight
WASHINGTON | Doctors in West Virginia drew national attention when they walked off the job to protest skyrocketing malpractice insurance rates. Lawmakers in Florida, Pennsylvania and other states are wrestling with how to keep their doctors from quitting. Consumer groups say patients are suffering.
Trial lawyers are bracing for fresh attacks on medical malpractice claims as doctors lobby hard for Congress to adopt caps and other legal reforms.

Sarasota Herald-Tribune (Florida)
January 13, 2003 Monday All Editions
Malpractice debate now a blame game
Hospital administrator Lindell Orr wrote two recommendations last week for area obstetricians fleeing Florida for Texas and Louisiana, where medical malpractice insurance is cheaper.
"I'm seeing doctors quit practicing at 55," said Orr, the chief executive of Doctors Hospital of Sarasota. "It's really sad. Conflicting diagnoses make it hard for consumers to know whom to blame if they have trouble getting treatment. Doctors blame lawyers. Lawyers blame insurance companies."

The Daily News of Los Angeles
January 12, 2003 Sunday, Valley Edition
HIGH COST OF LIVING; REFORMING NATION'S MALPRACTICE LAWS
THE new year started with a medical crisis that could spread. Surgeons at four West Virginia hospitals have been on strike since New Year's Day, in protest of malpractice insurance costs. Many operations were canceled, and some patients had to be moved out of state for treatment. In Pennsylvania, a similar walkout was only narrowly averted after an 11th- hour intervention by the governor.
The problem with medical malpractice is severe. A recent report by the Institute of Medicine estimates that at least 44,000 and as many as 98,000 hospitalized Americans die every year as a result of medical errors. Those figures exceed the number of people who die each year of breast cancer or in car accidents. Clearly, the victims of medical errors and their families deserve compensation. But resolving these cases under current tort law only hampers medical care.

The Patriot Ledger (Quincy, MA)
January 9, 2003 Thursday ROP Edition
Internet now aids in hospital choice; National group uses survey data for rating
   Patients trying to select a hospital can now go to an Internet site that lists how Massachusetts hospitals perform on three key measures that prevent medical errors.
   But not every hospital has submitted information to the voluntary survey, initiated by a national coalition of large employers called the Leapfrog Group.
   Among local hospitals, Quincy Medical Center is the only one that has not responded so far.
   After a call from a reporter on Tuesday, a Quincy Medical Center official said the hospital will file the information by the end of this month.

The New York Times
January 6, 2003, Monday, Late Edition - Final
Doctors Belong in Hospitals, Not Courtrooms
The new year started with a medical crisis that could spread. Surgeons at four West Virginia hospitals began their walkout on New Year's Day, in protest of malpractice insurance costs. Many operations were canceled, and some patients had to be moved out of state for treatment. In Pennsylvania, a similar walkout was only narrowly averted after an 11th-hour intervention by the governor.
The problem with medical malpractice is severe. A recent report by the Institute of Medicine estimates that at least 44,000 and as many as 98,000 hospitalized Americans die every year as a result of medical errors. Those figures exceed the number of people who die each year of breast cancer or in car accidents. Clearly, the victims of medical errors and their families deserve compensation. But resolving these cases under current tort law only hampers medical care.

AORN Journal
January 1, 2003
OR masks--safe practice or habit. ; operating room; Editorial
     During the past few years, there has been much discussion about surgical masks and questions about whether wearing them is an effective practice or a habit that has no basis in fact. (1) Are face masks useful or not? Do they prevent infections or not? This issue has not been resolved clearly. The majority of ORs continue to mandate the wearing of surgical masks; however, a few surgery sites have opted not to use surgical masks. This usually is justified as a cost-containment move based on the findings of one study. Researched-based effectiveness, however, has not been proven.
    MASK EFFECTIVENESS
    Reaching a conclusion on mask effectiveness is difficult because the available information is murky at best. In an attempt to empirically answer the question of effectiveness, a Cochrane review of all randomized and controlled research of disposable surgical face masks was performed. (2) This comprehensive review included information from individuals, manufacturers, and distributors, as well as AORN members. Researchers found only two randomized controlled trials comparing individuals wearing surgical masks with those not wearing surgical masks.

AORN Journal
January 1, 2003
Using aviation safety measures to enhance patient outcomes.
A recent report says that 44,000 to 98,000 Americans die each year as a result of medical errors. (1) This is the equivalent to more than 233 jumbo jets full of people crashing each year. In addition to human loss and suffering, it is estimated that medical errors cost consumers between $ 17 billion and $ 29 billion each year in additional care, lost wages, and litigation costs. (2) Consequently, methods of preventing medical errors and increasing patient safety in US medical institutions are being explored. In contrast to a two and one-half fold increase in the number of preventable deaths in medicine during the previous 10 years, the aviation industry has experienced a four-fold decrease in mishaps. In the past 20 years, the aviation industry has decreased errors caused by human factors 50% to 81% through safety training and standardization. (3) This article explores the potential benefits of applying these same safety training techniques and standardization practices to the health care arena.

Consumers' Research Magazine
January 1, 2003
The consumers' observation post.
DOWN ON THE FARM. The Coastal Alliance for Aquaculture Reform (CAAR) has launched its "Farmed and Dangerous" campaign, calling on restaurants, retailers, and consumers to boycott farmed salmon. Raised in net cages that float in the ocean, the salmon swim, feed, and excrete in confined areas with thousands of other fish. (One farm, for example, contains 14 pens, each 90 feet by 90 feet by 48 feet and stocked with 50,000 fish.) CAAR claims that farmed salmon, compared with those that grow in the wild, are not as safe to eat because they are treated with antibiotics and chemicals that enhance theft color; have more unhealthy fats and fewer beneficial fatty acids; and possess higher concentrations of polychlorinated biphenyls (PCBs) and other contaminants. When the salmon--as well as theft wastes and feed escape from the nets, they also pollute waters and endanger other aquatic life, according to CAAR.

Nursing Education Perspectives
January 1, 2003
Reframing nursing education to renew the profession: the keynote address from the NLN Education Summit 2002.
Welcome TO THE NLN EDUCATIONAL SUMMIT AND TO MAKING HISTORY, It all started in 1873 with the graduation of the first nursing student, Linda Richards. Twenty years later, a group of educators, meeting at the 1893 Chicago World's Fair, formed the first nursing organization in the United States, the American Society of Superintendents of Training Schools for Nurses. This organization led to the formation of the National League of Nursing Education and, eventually, to the National League for Nursing. Today, we stand on the shoulders of nurse educators from the 1890s on, who came together to discuss problems, propose solutions, and share best practices. * Looking far outside of nursing, two models set the stage for a discussion of how we must reframe nursing education to renew the profession. The second model comes from business, and I will allude to it later. The first model is inspired by the location of this Summit. We are in California, in a nation that was built on the notion of "going west" to find new opportunities and new ideas. Nurse educators are in the right place at the right time to solve our problems.

.1999 Institute of Medicine Report.