Gregg Meyer, MD
Director,
Center for Quality Improvement and Patient Safety
Good morning. I'm Gregg Meyer and I have the privilege of directing the Center for Quality Improvement and Patient Safety at the agency and a copy of slides and some handouts on patient safety are available to you there in the back of the room.
Let me start by asking you a quick question. How many people here have seen or heard about the report from the Institute of Medicine called "To Err is Human"? This is a report that was released in November, 1999 which really made everyone generally aware of a problem that I think that the medical profession had recognized for some time before that, but really for a number of reasons, had not confronted head on and that was that we have a major problem with our health care system and that problem not only leads to lots of costs and lots of inconvenience but it is actually, in this case, affecting lives very dramatically in terms of lapses of safety and people are losing their lives in American hospitals.
A couple of points that I want to drive home that were made by Institute of Medicine. First and foremost is that number up there; 44,000 to 98,000 Americans die each year in American hospitals because of lapses in safety; because of problems with medical errors. Many of you will know that there has been a lot of debate about that number and so the medical profession, first in the Spring of 2000 and again this last summer in the Summer 2001, had very public debates about whether this number is right. What I can tell you as the federal official who leads research on patient safety, is that whether it's 15,000, 44,000, 98,000 or 200,000, I don't care. I don't care. The reason why I don't care is because whenever I talk to an audience of providers or policy makers, everybody agrees with one fundamental point, and that is it's too many. And because it's too many we can get to work on the problem right now and still work on getting those numbers better. I'm a scientist; I want those numbers to be just right. I want to know what that rate is but we're not there yet in the science. That's something that our agency is working on improving but until we get to that point we don't need to stand around and decide whether or not it's 15,000 or 200,000 to begin to tackle the problem. We need to begin that work right now and every provider audience I've talked to has agreed with that point.
The second one is that these problems are, for the vast majority, systemic. What I mean by that is that through traditional ways that we've handled safety problems in hospitals and doctor's offices and long term care settings and home care settings has been to name, to blame, to shame, and to train. And guess what? We've been doing that for a very long time and it doesn't work. And the data is very clear on that; we are having too many problems out there to really rely on that traditional approach. We need to take a systemic approach. I'll give you a very concrete example. There are instances every single day where patients get the wrong medications or get the wrong dosages because a hand written prescription is misinterpreted. What's the solution there? The solution there is not to give doctor's handwriting classes. It's not to give pharmacists classes in reading messy handwriting. I have had everyone since my second grade teacher trying to improve my handwriting and guess what; it's not happening. But I see patients every week; I write many, many prescriptions each week and I know for a fact in the last 9 years that I have never had a single patient who had any difficulty in terms of a prescription being misinterpreted. Why is that? It's because it's not about the handwriting; it's about taking handwriting out of the equation. I enter my prescriptions over computer in the military health system. It's a system that's implemented this program widely. It's the system stupid! It's not about the handwriting; it's not about the individuals; how can we fix the problem more generically. How can we make it that the right thing to do is the easiest thing to do. That's the systemic approach to safety.
When this report came out from the Institute of Medicine it was followed 90 days later by a report to the President from various aspects of the federal government; a real example of how the FDA, the CDC, the Center for Medicare & Medicaid Services, we at AHRQ, the NIH, the Veteran's Affairs, Department of Defense; Department of Transportation, Commerce and Labor, all can work together. We came up with a comprehensive plan of what the feds could do to help promote patient safety and that's available to you and the reference for that is in the materials.
How big a problem we have out there I think is well illustrated here. This is a slide that was developed by one of the nations leading experts in patient safety issues, Lucien Lee. What this shows is on the vertical axis there, going up and down, is how many people each year are dying as a result of an activity. On the horizontal axis is the number of times you need to do that activity before someone dies from it. Well you see on the lower right hand side here is that something such as European railroads and nuclear power are ultra safe; that people die in these instances very, very rarely. What you see on the left side of the slide there though is that health care when you look at the existing data today again, it's imperfect, but the existing data today suggests that the health care system is approximately as safe as bungee jumping: very, very dramatic.
This is some data from a pole that we do; it's a Kaiser Family Foundation nationally representative as a group of Americans who say 1) how worried are you about encountering certain services and among those we asked for an example were commercial airline flights and buying food in a grocery store and what the bottom line of this is that the American public gets it. What they say is they say I am more worried about seeing Dr. Gregg Meyer in his out-patient office than I am stepping on a commercial jetliner. And the truth is, is that's right. They have that dead-on right. They should be more worried because it is in fact a more dangerous system. What they have wrong are the proportions here because in fact commercial flights are so much safer even after figuring in September 11th. Commercial flights are so much safer that it would just be a sliver on this bar graph.
On the right hand side here, what you see is you see that 6% of Americans say that they have personally been affected by a medical error, by a lapse in safety in the last year. In health care what that's called, that's called an incident rate. How many times has this happened over the last year? What I can tell you is that to my knowledge, the only condition with an incidence rate of greater than 6% in the general American public is the common cold. The influenza on a really bad year but year to year it's the common cold. So this is as common in people's perceptions as the common cold is. So it's very, very dramatic. This is why the public gets it and that's why they're knocking on all your doors and writing those letters telling you, get out there, fit it.
What you see as policy makers is really only the tip of an iceberg; that is as you see those incidents when a patient is actually harmed and often harmed in a very dramatic fashion. For example, many of you in your states have dealt with issues related to wrong site surgery. A patient having the wrong leg amputated for example: very, very dramatic. What I would ask all of you to remember is that in fact those are just the tip of the iceberg. Those are very, very rare events but underneath them are a huge number of events that never come to our attention because the injury is relatively minor, or in fact we just get lucky or we recover very well and we have what we call a close call and near miss. For you as policy makers, the take home point here, I think is best illustrated by an example of driving. How many people here in the last 6 months have been involved in an accident that was fatal or near fatal to somebody involved. That's great news, none of you. How many people here have "almost" been involved in an accident that could have been fatal or near fatal? If you're from the Washington, D.C. area and you drive on the Beltway everyday like I do that's a daily experience. And the point that you need to recognize is that we can learn as much from those times when something bad almost happens to when something bad really does happen. We don't have to wait for the body bags to tackle the problem. We need to learn from all of those events because that instance where the wrong patient had their tonsils removed in the hospital probably almost happened in some other hospital in your state just a few weeks before. If we took the opportunity to capture all that information about close calls, we could learn from it and prevent us from having to confront that ugly tip of the iceberg.
Another point that's really essential to an understanding of the approach to safety and error is that we think of error as two major types: active area, that's when somebody actually does something. In health care that's when a doctor or a nurse interacts with a patient. But there is also what we call latent errors; these are delayed consequences of organizational rules or of public policies and this is again where you come in. A concrete example here. The Titanic was the unsinkable ship; the world's largest cruise liner. In 1912 on its maiden voyage it went down. You all know part of that story. Part of that story is is that they were trying to set a trans-Atlantic crossing record; they were going into an area which was known to be an ice field and the captain pushed the ship as hard as he possibly could because he wanted to break that record. They hit an iceberg and they sunk. That was an act of error. That was the captain making a decision piloting that boat and that boat went and crashed into the iceberg. But in fact what many people don't know about were the latent errors in that decision and that was the owner of the White Star Cruise Line, Bruce Eshme, made a very, very clear decision about two months before the Titanic sailed and that was he decided to have a larger promenade deck for paying passengers so they could walk around, rather than add the 1,500 lifeboats that would required to get the remainder of the passengers off the boat in case it sunk. Who is responsible there? Who was the one that you should name, blame, shame and train for that problem. And the answer there is you need to focus on both the sharp end, that individual who pushed that boat too hard but you also need to focus in on the blunt end. Patients in intensive care units not getting proper care. They're dying because they're getting nosocomial; hospital acquired infections. Part of that is is maybe people aren't washing their hands enough but maybe there's an organizational or public policy decision around staffing that's also had a dramatic role there.
There's some examples of how we can improve this very dramatically and one of the best comes from Paul O'Neil who before he was Secretary of the Treasury, ran Alcoa Aluminum. Alcoa Aluminum is inherently a dangerous business. What they do is they take big rocks out of the ground, they grind up that balk site, they melt it down in red hot cauldrons, they roll it out into sheets of metal, punch it out into cans and other products and put it on trucks and ship it out. That is a dangerous industry. And what Paul O'Neil did is he came into that dangerous industry and he said even though Alcoa Aluminum's safety record was actually better than most in the industry, he said we are going to get to zero. We are going to have zero fatal and disabling errors and he did it. And the way he did it was he focused in on system solutions, on how to make things safer. Whenever they saw a sign in a factory that said "caution" or "beware", he said why is that sign here. That sign here says something. That sign says somebody didn't think enough about the worker to design this factory safely. Let's redesign that area to make it completely safe so you don't need a caution sign. And by going through a series of steps that included committing adequate resources, recognizing that solutions come from unexpected areas and having a culture of safety; having openness about discussing problems, that that allowed them to get to zero.
Another example, I won't spend much time on, is that of naval aviation. Naval aviation in the 1940's and '50's was quite dangerous. I'm from the Air Force and what I can tell you is that I would never, ever land in a plane on a moving air strip, but the Navy does that all the time with carriers and what they did was they over a period of time extruded a number of systems approaches that got them down to the point where Naval Aviation improved its safety record very dramatically. Health care can do the same. We have to attend to that sharp end, what providers are doing and the blunt end, about our policies.
What we have done as a research agency is we went out and said what are the research questions that we can answer that will improve patient safety and we did this in a fundamentally different way than we usually approach research. The way we usually approach research is we get the best and brightest researchers from around the country, sometimes around the world, to sit around the table and say what's the next level; what's the next area that this research should go it. We did not do that in patient safety. What we did in patient safety instead is we asked patients, both individual patients and advocacy groups; we asked providers, individual doctors, individual nurses, national associations, we asked hospitals, we asked health plans, we asked purchasers, large and small and policy makers at the local and state level and said to them what is it that we can invest in in terms of doing research. What are the questions that we can answer that you can use to improve patient safety? So this is truly a user-driven agenda and we had the opportunity in Fiscal Year 2001 to put in a $50 million research program to focus in on those user needs and many of them were identified by your colleagues, by state legislators and by state policy makers.
The first and foremost issue they felt we should focus on was learning about health system reporting. What can be done with the data that's currently collected? For example, there are many states that have error reporting systems and I think to use the somewhat pejorative term I think they are best characterized as data graveyards. You collect information but what do you do with it? How is it analyzed? How is it used to make health care safer for the next patient in your state? We think that we need to learn a lot more about how to make that process work. So in fact we have some grants that have gone to the states of Massachusetts, Utah and New York to learn about those state systems and to answer an earlier question, are really directly to state health departments. So there's a very, very direct partnership there.
We're also trying to improve our knowledge base on patient safety through Centers of Excellence. We're learning about how to use computers and informatics. We're looking at the effect of working conditions. A very vexing issue for many of you is staffing ratios. The science behind that is very, very slim and we're trying to improve that situation and finally trying to get those answers disseminated out there to providers and policy makers.
With that said what we recognize fundamentally is just like politics, all patient safety is local. The federal government can try to facilitate some of the work that's done in patient safety but the truth of the matter is, is that at the states, it's the individual hospitals and it's the doctors and nurses who work in them who are going to be making patient safety every day. Patient safety doesn't happen in the Halls of Congress; it doesn't happen in a federal research agency; it happens in outpatient clinics; it happens in hospitals; it happens in long-term care facilities; it happens in people's homes when they receive home care. We are trying to facilitate that and again, as Carolyn pointed out earlier, we try to provide evidence to guide your wise decision making.
Here's an example of a problem that many of you either have confronted or will confront and that is how do you interpret this slide. How do you interpret this slide in front of me? This slide shows; this is a hospital and this is real data that looked at the rate of transfusion errors that were reported in that hospital over time and what you see is they had a dramatic jump at the end of this particular year between December and February, they had a dramatic rise, about ten-fold in the number of errors that were being reported. What's going on here? Is this something really bad? Is this a hospital that you should avoid? Have they messed up their labeling procedures? Have they fired people that work in the blood bank? No. In this particular hospital what they did was they implemented a program where they told all the people that work in transfusion medicine, you know, we have to be more open about things that are going wrong or almost going wrong when we give blood and we need to learn from it. So in fact what I will tell you is very counterintuitive. You want to go to the hospital with the highest reported rate of errors. Let me say that again. You want to go to the hospital with the highest reported rate of errors in this instance because they are a learning organization. One of your jobs as policy makers when you deal with the media is you're going to have to explain this kind of data in your state and you need to know whether or not that was an institution that had a very focus problem and maybe again; they had something that went terribly wrong with the way they handled blood or whether or not they're in fact getting it together and becoming a true learning organization. There are a number of things that the states can do, a number of unique levers that you have. For example, you really develop a lot of the policy and environment to support safety. Do the providers, the doctors, the nurses, the hospitals, the long term care facilities, the home care agencies, do they in your state feel like they can discuss problems with safety openly. Can they learn from that? A lot of that will be set by state policies related to peer review protection. I would commend to you under recent work that has been done in the state of Pennsylvania with their work on tort reform where they built in a very important patient safety improving activity in terms of trying to protect data for learning. So there are some national models that are emerging.
You also have some unique levers in terms of state licensure. It is really one of the ways that the hospital system, doctors and nurses are regulated. Those licenses come from the states. That's something that you can use to help promote safety.
You also can address very focused local issues. For example some of you have real issues in terms of rural health care and safety in those settings. It is well recognized that small rural hospitals are going to be quite unlikely to go out and make tens of millions of dollars of investments in computer systems. What is it you can do with those institutions?
You can promote spread. You can try to get that safety message out there and you really can add voice. You need to get up to speed on the issue so that when in fact you're dealing with that curve with the media that you're able to talk about whether or not this is a real problem or this is really showing that your state is moving forward in terms of learning about patient safety.
There's going to be a lot of push for many of you to consider making investments through public programs in terms of informatics and computer technology to improve safety and what I will tell you is that one of the things that we learned when we held that national summit and the users told us where they needed research. There's a great quote from that and that was "that to err is human; but to really screw up you need a computer". And the message there was an important one and that is is that we should automate health care where we can and where we know it will work, where we know it will work. So we need to build the evidence to know which of those gadgets and which of those systems are really going to make a difference and which of them are just going to simply automate our ability to produce errors and cause safety problems more efficiently and more often. So we really need to exercise on some caution there. We'll hopefully generate some information there.
A really simple concrete thing that you can do in terms of the Iowa centenarians who come in with their prescriptions, here's something you can do immediately. There is a document; it is on our website; it's both in English, it's in Spanish; it also has a low literacy version. You can download it, put your state logo on it or have your hospitals put their logo on it. These are 5 things based in evidence that patients can do to improve their safety. The message here is in that patients are responsible for their own safety. The message here is that they do play a role because patient safety has worked for patients, for providers, for policy makers, for purchasers, for all the players. But here are things that patients can do. Each of these is based in evidence so speak up if you have questions. Keep a list of all the medications you take: very specific instructions. It's not just the medicines that you take from doctors, but it's the herbals, it's the supplements, it's the over the counter you also take. Make sure you understand what happens in surgery. Talking with your doctor about your options for care. This is available to you; it's based in evidence. I've used this is my practice personally and it absolutely works. We want you to help us get it out there.
We also do some research across a number of interventions. Carolyn Clancy talked about how we try to provide evidence for decision makers: here's an example. This is a report that we did that looks at 79 different things that hospitals and health care providers can do to improve safety and it says what is the evidence that these work. We don't tell you which ones, any individual hospital or group should invest in; what we say is here's the evidence base; you should make a wise decision based on this and again, this is available to all of you free of charge and the executive summary of it really gives a great overview of a whole range of activities that could be accomplished. What a large academic urban health center should do and what a rural hospital should do may be very different but all of them should base their decisions on evidence; we're trying to provide that to you.
What we want to do as we move forward in safety is we want to build partnerships. We are a small agency. We want to be the mouse that roars and the way that we do that is we work in partnership with others and states are very important, especially because you have a lot of unique levers. We want you to try to implement some of our products. We'll make them freely available to you. We want you to maintain the momentum in fact, what safety has done is it's made many people crystallize their thinking not just on that tip of the iceberg that we call safety, but health care quality in general and we think that we need to build on that momentum. You can get updates on our work in safety by going to our web site. Thanks.
QUESTION: Sen. Jim Jensen, Nebraska. I started out as a contractor many years ago and the first thing I did when I bought a saw was to tie up the guard for the blade because it was in the way. So in construction I soon found out that that safety doesn't cost, it pays. What I found in Nebraska, we have a lot of rural hospitals, I absolutely believe that yes we should not go to the written prescription formula but through a computer driven system, which is very easy. But we meet great resistance on those rural hospitals that say that we cannot afford that, the rural clinics. But also along with that I see it in medicine the same thing that we see in manufacturing and everything else that there is a reluctance to actually do reporting because they feel it opens up a liability question for them later on. How do we balance those two?
I think that that is something that we have at the federal level that some real struggles and that is trying to one the one hand to promote a culture where people can talk freely about problems and learn from them. On the other hand maintain some level of accountability and guess what? That's hard work. That's hard compromise; that's hard thinking they have to apply to that problem. I'll tell you the way on the federal level that we are addressing that and that is we have moved away from, for example, reporting on things like medication error rates, and instead what we are considering very broadly with our colleagues at CMS and others is not that someone would be able to go to their local newspaper and look at whether or not hospital A had more medication errors than hospital B, but know what systems hospital A has in place that make providing medication safer and have that comparative information so you could go to the paper and you could say oh, hospital A, they enter their prescriptions by computer and they have a pharmacists that goes on rounds and they do these things and those things aren't available in hospital B. Maybe if I have elective surgery I should think about going to hospital A. It's taking that systems approach. It's not asking what happened with this individual patient saying what systems have you put in place. So that's the approach that we have taken, moving away from looking at those individual things.
The real, real levers though I think for opening this all up is promoting the conversation about safety and there are two things that are key there. One of them is making people feel safe in terms of discussing the issue and that's where the issues of peer review protections are so important. As you may or may not know there's been a federal effort and it's mostly driven by the senate side to try to get some sort of federal peer review protection related to safety in place that has been waxing and waning. I hear now that that bill may be introduced on Monday, we will see. I've heard that a number of times over the past 12 months but there are things that the states can do. Again, Pennsylvania provides I think an example of what states can do there.
The second thing that you need is you need is a cultural safety and that is something that is provided by leadership and all of you are in leadership positions where you can effect this. A really short Air Force story that will illustrate this. There's an Air Force base down in Texas, it's now been bracked but it was open when I was in active duty and their mission was to repair C-5 Galaxy's, the huge cargo planes, and they had a new commander; a new general took over that Air Force base and that commander arrived at that Air Force base and he announced to all the non-commissioned officers who worked on the flight lines repairing planes, he told them the first time anyone who works for you tells you they made a mistake, I want you to call my office immediately, night or day. Well guess what? The next day some young airman over-torqued a bolt on an engine, went up and told his superior that he had just made this mistake and his superior said well, okay, here's how you fix it, but by the way I've got to go call the general's office abut this because you made a mistake. He made the phone call and two military policemen in a jeep came; they took that young airman and they brought him directly to the general's office. So you can imagine some 19 year old kid, going to meet the new commanding general of military police. I think that his pants were probably wet by the time he walked in the office. When he walked in that office what he was greeted by was the general, outstretching his hand to him, shaking his hand saying, son, because of you, we're going to have a safer Air Force. Thank you for telling us about your mistake. Click, the base photographer took the picture; the story was on the front page next day and they created a culture of safety. Your job as leaders in your states working with the providers in your communities is to create that kind of culture. I don't think it's something that takes years to build; I think it's built by leadership and you have an important role there.
QUESTION: Rep. Elaine Fuller, Maine. Kind of following up on your culture of safety, in one of your slides you talked about licensure and certification as being one of the vehicles and I would suggest that licensure and certification as a vehicle to do this is a very negative incentive because of the penalties for deficiencies and all that kind of stuff. In Maine we just passed a medical errors and improved patient health bill and it does deal with the issue of reporting but having confidentiality, having reports done on an annual basis that looks at the data that's been reported and the whole idea is to promote a culture of safety. At the present time it applies to health care facilities except nursing homes so it's hospital based pretty much. But it is a step in dealing with the issue of medical errors and we think it's a real positive step and we're looking forward to having it implemented. It's a separate unit from licensure and certification and it deals with errors that hospitals are required to report, "sentinel events". So we think it's a good move.
I think it's a great move. I also think that there are complementary activities here and it gets back to that first issue in terms of balancing accountability and promoting a culture of learning and that is is that I think what you've done is a great step in terms of promoting a culture of learning. At the same time one of the things you didn't hear me say here was blameless and that is because unfortunately there is a very, very small minority of providers of systems that are truly reckless. This happens. One of the ideal complementary approaches to balance that accountability v learning is to do exactly what you did on the learning side, and also on the accountability side where you do have that level to make sure that your licensure and certification process are going to structured such that they are going to pick up individuals whose patterns of practice are reckless. They are a very small, small minority and I have a very strong feeling about how the scales of accountability and learning should be tipped. But that also needs to be dealt with and so those are two places where I think states can really compromise this very, very nicely.
QUESTION: [Rep. Fuller] Yes, we had the input from all the hospital association, the medical association, etc. so there was a lot of support for those that are out there providing services for what we developed and we just think it's going to be a great program.
So you should be the point of contact for the other people here in this room that want to get this done because that is absolutely great work and again, the federal government, it doesn't have the ability or levers to do what you're able to do at the state level.
QUESTION: Sen. Pat Miller, Indiana. I wanted to speak to this question as well. There's a health safety institute that has been in Indiana twice, I've been to their meeting; it's private hospitals that sponsored or putting in $25,000 and they are doing a lot of education but one of the things they shared with us is unlike the Navy, the reporting, we do have the litigation issue and they said the things that the state could do to help most would allow for a pool of sharing the kinds of mistakes that occur and say that all that information in that reporting center is not discoverable. It doesn't mean the information can't be used in litigation, but they can't go to that network where the study and the reporting and resolving the problems are discussed. They have to find it someplace else and I think that is something we can do is say that that pool of information isn't discoverable under litigation.
That is in fact the peer review protection model that is currently under consideration at the federal level.
QUESTION: Rep. Dennis Arakaki, Hawaii. I have a couple of issues I hope you can address. No. 1, although it's anecdotal there seems to be a lot of errors being made in the mental health arena I think largely because of confidentiality issues as well as the mental capacity of the consumer. I'm just wondering if there are separate studies that you have on that issue. No. 2 is we're always looking at expansion of both scope of practice and prescriptive authorities for different health care professions. I'm wondering if you have any also definitive research on the effects of these?
Let me deal with those separately. In terms of the first one on mental health, a lot of the data, in fact the vast majority of the data that was used by the Institute of Medicine, report comes from the hospital setting and that is for two reasons. One of them is that hospitals are pretty complex and one would think that if there are safety problems they would be there in hospitals but frankly it's because, it's the phenomenon of the drunk looking under lamp posts for the keys. That's where the data is; that's where the light is shining. We don't have a lot of data for example for looking at safety issues in ambulatory care. We have much less than that for looking at long term care, much less than that for looking at home care and mental health is somewhere in that spectrum as well. So what we are trying to do is we are trying to learn as much as we possibly can in settings outside of hospital care. For example, some of our Centers of Excellence are focusing in on all of those areas. We also have two targeted grants that are looking at issues related to mental health and what I would commend to all of you, there's a good idea of our research portfolio, there's a handout here on the table relating to that and our website has details of all of those grants. You can also count on us to make announcements about the results of those studies available to all of you, and that's either through our research activities newsletter, which you can subscribe to and we'll send it to you for free or to get on our electronic mailing list to get some updates about that work.
The second issue was in terms of scope of practice and there we do have some of our work in working condition and grants focused on working conditions looking at things like staffing ratios, hours of work, sleep and fatigue issues; not unnecessarily focused on scope of practice. The one I know that many states are struggling with is directly related to anesthesiologist and nurse anesthetists for example. One of the studies in that area was sponsored by our agency and a follow up study to that is under consideration and that is something that we have been discussing with the Center for Medicare and Medicaid Services. But again, the definitive data on that is not yet available.
QUESTION: Let me add a cautionary note on the issue of the confidentiality or the lack of discoverability. In my state four years ago I foolishly allowed an amendment onto one of my bills, which alleged to protect information in the hospitals that would have otherwise been undiscoverable within the medical association or nursing association until such time as a complaint was found to be valid. That has with the help of an attorney general's opinion rapidly evolved into a climate of secrecy so that no information is now discoverable. I can't even get information about my own complaint that they may have filed. The results have been devastating. Nine people dead in the hospital in Nacona, before the information was discovered because of some fear of litigation and I would suggest to you that nine dead people deserve to be litigated. We now have a situation in San Antonio with a hospital there that is the same kind of issue. I am aware of the pressures in the tort reform movement to do this, but I think we need to be very, very cautious and I know you're going to say it's discoverable other ways, but let me tell you once that door starts closing it's slammed shut in a hurry.
It really gets back to is letting people feel safe to talk about these problems, on the other hand having a culture of openness. So what you have is you have a situation where people feel safe but they also have a culture of secrecy. And you have to do work on both ends. The other thing I would remind you of what we need to be able to do is we need to make sure that whatever litigation would arise, for example from the deaths of those nine patients, not only will have an impact on those direct providers that everybody can learn from what happened there. So even in those cases that lead to litigation we need to take them as learning opportunities. It is absolutely frightful, for example, to go back and look at some very dramatic cases. One example is a case in New York State, in 1986, when a patient was given the wrong medication in a spinal injection. That medication was neuro-toxic. It actually destroyed their spinal cord and brain. He died about 10 days later as a result of that incident. It resulted in a huge lawsuit. Within 3 years that exact same problem occurred in the State of Pennsylvania killing a three year old. Again in the state of New York killing an 18 year old and in the state of Iowa, killing somebody who was 21. So we need to make sure that yes, there are some things that should be litigated but we also need to make sure that we are learning from them as well. So there's work to do I think on both sides of the problem.
COMMENT: It's the Bridgestone/Firestone issue. The lawyers are criticized for sealing those settlements, which would have revealed that there was a problem with the treads coming off these tires.
Right: there is not openness there.
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