You know, our healthcare system in the United States is a hot topic of conversation amongst patients, politicians and pundits right now. This increasing scrutiny is driving a real transformation – some would say a true revolution – to reinvent patient care that is focused on safety, quality, accountability, and transparency!
I am personally distressed to hear of a woman dying on the floor in a Los Angeles Hospital Emergency Room while on-lookers desperately tried to gain the attention of the hospital staff to help her, and even called 911 not once, but twice in desperation for assistance. What is even more disturbing is that no one at the hospital – no doctor, no nurse, no administrator - had reached out to this poor woman’s family to console them, or to admit that a serious error had been made, or to engage the family in the processes of analysis to understand the root causes that allowed this tragedy to occur.
This is a particularly shocking example of what I believe is wrong with our healthcare system as it exists today! Hospitals, medical plans, doctors and nurses fear retaliation, fear retribution, fear that lawsuits may be filed against them, and even fear that they will be fired, when errors occur. Those fears promote a culture of “cover up” in our healthcare system that thwarts any meaningful discussion that could lead to productive changes in the organization of healthcare delivery. Those fears prevent a transparent and honest conversation with the grieving families so that they may gain closure in the understanding of what happened to their loved one.
I have spoken to literally dozens of families who have fallen victim to medical errors and they all express one common theme. And that is their sincere wish that someone in authority, their doctor, or a hospital administrator, or even the nurse at the bedside, would simply meet with them, and speak honestly and openly about what happened to their loved one.
I have spoken to countless doctors, nurses and hospital administrators who themselves also grieve over a medical error, but are forced to remain silent in the fear that any admission of wrong-doing may result in a grave outcome for their own livelihood or future.
This apparent stalemate must be broken if we are to promote a future healthcare system that is safe, that is high quality, and that can be transformed from its mistakes. I believe that we must regain focus upon the patient in healthcare, and push aside so many other conflicting interests that may influence medical decision-making. I believe that doctors, hospitals and medical plans should make their outcomes transparent, and should be accountable to their patients, and the families, that they serve.
These are but a few of the new ideas that will lead healthcare into a new era. I have devoted my own career to promoting safety and quality in healthcare, and it is my sincere hope that through education, on-going discussions, and yes, maybe even legislation, that we can reap the rewards of safe healthcare, and prevent such tragedies as a woman dying on the floor in an American hospital emergency room.
Thank your for your attention. I hope that the information on this blog may be of some help to you!
Irvin B. Krukenkamp, MD
www.DoctorK.org
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