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Medical Errors and Patient Safety

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With support from: Lowell Institute
Date and time
Tuesday, May 11, 2004

A panel of professionals weigh in on the shocking 1999 The Institute of Medicine report on medical safety. Panelists include Lucian Leape, Connie Crowley Ganser, and Linda Kelly. The event is moderated by John A. Fromson. The Institute of Medicine reported in 1999 that health care in the United States is not as safe as it should be, and that as many as 98,000 patients may die each year from preventable medical errors. How far have we progressed in five years? How do doctors, nurses, and other health care workers approach patient safety? What is the responsibility of the patient for patient safety? How can we make medical care better? .

Lucian Leape is a health policy analyst whose research has focused on patient safety and quality of care. Prior to joining the faculty at Harvard in 1988, he was professor of Surgery and Chief of Pediatric Surgery at Tufts University School of Medicine and the New England Medical Center. Dr. Leape is internationally recognized as a leader of the patient safety movement, starting with the publication in JAMA of his seminal article, "Error in Medicine" in 1994. His subsequent research demonstrated the success of the application of systems theory to the prevention of adverse drug events. He has been an outspoken advocate of the nonpunitive systems approach to the prevention of medical errors and he has talked and written widely about the need to make patient safety a national priority. Dr. Leape was one of the founders of the National Patient Safety Foundation, the Massachusetts Coalition for the Prevention of Medical Error, and the Harvard Kennedy School Executive Session on Medical Error. Recent honors include the Distinguished Service Award of the American Pediatric Surgical Association, the Donabedian Award from the American Public Health Association, a Robert Wood Johnson Foundation Investigator's Award in Health Policy Research, and honorary fellowship in the Royal College of Physicians and Surgeons of Canada. In 2003 he received the duPont Award for Excellence in Children's Health Care. In 2004, he received the John Eisenberg Patient Safety Award and Modern Healthcare named him as one of the 100 most powerful people in health care. Dr Leape is a graduate of Cornell University and Harvard Medical School. He trained in surgery at the Massachusetts General Hospital and in pediatric surgery at Boston Children's Hospital.
Connie Crowley Ganser is the President of the Massachusetts Coalition for the Prevention of Medical Errors and Corporate Director, Performance Improvement and Compliance at Children's Hospital, Boston.
Linda Kenney remembers the day her life changed forever. It was November 18, 1999. At the time, she was a 37-year-old wife and mom of three and she was scheduled for a total ankle replacement. For Linda, operations were a way of life. Born with bilateral club feet, this was to be her twentieth surgery. She said goodbye to her husband and went to the pre-operative area where the block was performed. Moments later, she was near death, in full cardiac arrest. A rare and frightening complication had occurred. Anesthesia had entered Linda's blood stream and stopped her heart. A Code Blue was called, and when her cardiac function could not be restored, she was rushed to a cardiac OR where her chest was opened and her heart was connected to a bypass machine. It saved her life. When she was discharged, Linda was given instructions on how to manage her physical recovery and obtain help from a visiting nurse. But, she says, no one informed her of the emotional impact an event like this would have on her or her family. Linda then made some difficult decisions: She was not going to sue the doctor or the hospital as many people had assumed she would do, and she wanted to get back on the horse and reschedule her surgery. She also decided to contact Dr. van Pelt and ask him to join her for coffee so she could let him know that she didn't blame him and that she believed this was a truly unanticipated outcome. In June 2002, Linda founded Medically Induced Trauma Support Services (MITSS). Dr. Van Pelt helped get the organization started and is now chairman of the MITSS Board of Directors. Linda has worked with hundreds of patients and their families, as well as clinicians who have found themselves on the sharp end of an adverse event.