Like Two 747’s Crashing Every Day: the worst airline accident in history

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What are the three leading causes of death in the United States? Most people quickly identify heart disease and cancer, which in fact respectively account for about 750,000 and 550,000 deaths annually. The third leading cause of death is usually a guess: Alzheimer’s? Diabetes? Obesity? Traffic accidents? Airline crashes? With at least 440,000 deaths a year almost no one guesses the correct answer: medical errors. The practice of medicine, including diagnosis, treatment and surgeries, is the cause of deaths that approximate the number of fatalities of two full capacity 747’s crashing every day. If on one day there was such a loss of life due to airline crashes there would be massive investigations and media comparable to the March 1977 crash in Tenerife considered the worst airline accident in history: the search for black boxes, analysis of the weather, integrity of the equipment, the qualifications and behaviors of the pilots, and the airline’s quality assurance procedures. If two 747’s crashed on two consecutive days, there would be implications of terrorism, accusations of conspiracy. If two 747’s crashed on three consecutive days, the impact and reaction are unfathomable, but one could only guess that mass panic would set in nationally and internationally. Yet 1,200 Americans, twice the number of the casualties at Tenerife, die day after day, 365 days a year with the resulting death toll being that of the annual wiping out of the populations of major US cities: Atlanta one year, Sacramento the next, Miami the next, year after year. These tragic losses are not just numbers. They are our grandparents, mothers, fathers, siblings, our children and our friends. They are the victims of wrong site surgeries, the aorta sliced instead of the renal artery, over-medication due to a misplaced decimal point, a misdiagnosis of a hypokalemia leading to cardiac failure, a hospital acquired infection from inadequate cleanliness of supplies, equipment and hands, or a sponge left inside the surgical site.

How this is happening without public knowledge, panic and outrage is a simple question of multiple determinants. There are explanations when required, which is seldom. Hospitals are complex environments. To Err is Human, as the 1999 Institute of Medicine report citing the underestimate of 98,000 deaths a year was titled. In 2013, John T. James, PhD, a NASA toxicologist who’s own son was the patient who died from misdiagnosed hypokalemia, published his robust study based on findings using four different research tools, in the Journal of Patient Safety. His study results more than quadrupled the IOM number to 440,000 deaths a year. To err may be human, but in truth, all too often decisions for care are dictated by financial initiatives to benefit the hospital rather than the best care of a patient; hospital error reporting that is voluntary ; hospital quality assurance that is actually cover up ”risk management”; the autonomy of doctors who are never evaluated, tested or required to upgrade training and cannot admit that they have made a mistake. Atul Gawande, MD, in his book Complications stated, “There is a saying about surgeons, meant as a reproof: sometimes wrong; never in doubt.” Government, regulatory agencies and patient advocacy organizations have pressed for changes in reporting, hospital policies and procedures, and checklists ironically based on those used in the airline industry, but the number of deaths has not decreased, the needle on the scale of improvement hasn’t budged.

The Veterans Administration hospital scandal in June 2014, exposed the deaths of at least 40 veterans who died due to medical errors including delays in their diagnosis and treatment. But months and even years before the exposure, when lives could have been saved, employees in the hospitals had been raising concerns and reporting dangerous practices, inadequate care, and fraud. These whistleblowers were intimidated, threatened, harassed, transferred, put on administrative leave without pay and fired. Not unusual treatment for whistleblowers as recent high profile cases have been broadcast in the news.   The VA is now hustling to correct care deficiencies and provide remedies to the whistleblowers, but not enough to restore lives and repair permanent damage.

The Veterans hospital deaths as tragic as they are, are the tip of the iceberg of the 1,200 a day medical error deaths. Patients are dying in private hospitals, public hospitals, community hospitals and super-sized academic medical centers. Within these facilities whistleblowers have attempted to report and correct wrongdoing and system flaws that lead to the daily death count as well as almost 4 million errors a year that leave patients disabled, damaged and compromised. Like the whistleblowers in the VA hospitals these health care employees, nurses, lab staff, managers, and some doctors themselves, have lost their jobs, their health insurance, their retirement benefits, their professions, and ability to find other employment. Dr. Marty Makary states in his book, Unaccountable, which documents his experiences of patients suffering from medical errors, “if I was labeled as a whistleblower, my career would be shot.” Telling the truth in health care is risky business.

There is a long history of retaliation against those who have spoken out against the medical status quo that puts patients at risk. In 2008, Dr. James was presented with the Semmelweis Award, named for Dr. Ignatz Semmelweis, considered now the father of patient safety.   The observational case control study conducted by Semmelweis in the mid 1800’s indicated that women and babies in hospital maternity wards were dying because doctors were not washing their hands after examining cadavers and then delivering babies. With a maternal and infant mortality rate of over 18% in hospitals where doctors delivered babies in comparison to a 2% mortality rate for deliveries at home with midwives or even poor women whose babies were delivered in tenements, Semmelweis wrote a treatise, The Etiology, Concept and Prophylaxis of Childbed Fever, on the imperative for doctors to wash their hands between patients. The medical community was outraged that he would state that doctors’ lack of clean hands was killing women and babies. Semmelweis was declared mentally unfit, and confined to an institution where 14 days after his admission he was mysteriously found dead, presumably beaten to death by guards. His work was not recognized as valid until two decades later after Pasteur and Lister presented evidence of germ theory. In 1965, to mark the 100th anniversary of his death, Semmelweis was honored with his image on an Austrian postage stamp. Doctors in the United States today are still less than 50% compliant in hand washing.

Despite current legislation in healthcare law, shooting the messenger is still the general practice in medicine. Retaliation is often couched in legal defense of protecting patient confidentiality, and hospitals misuse HIPAA as a way to attack whistleblowers. But more effective to deter whistleblowing, hospitals maintain cultures of don’t talk or else.   Special Counsel Carolyn Lerner of the Office of Special Counsel, a whistleblower protection agency, has stated that 125 VA hospital employees have filed retaliation cases. Three of the whistleblowers she has represented are Dr. Katherine Mitchell, Paula Pedene and Damian Reese. Mitchell reported understaffing and inadequate training of staff in the emergency department at the Phoenix hospital and was removed from her position as the co-director of the emergency care. Pedene, formerly the hospital chief spokesperson, was re-assigned to a job in a windowless basement office after she reported financial mismanagement in Phoenix. Reese complained about the data manipulation that covered up delays in care; he was given a negative performance review. Lerner stated in a PBS report, (September 29, 2014,) “Dr. Mitchell, Ms. Pedene and Mr. Reese followed their consciences and reported wrongdoing, and their efforts have improved care and accountability at the VA,”

The recent British National Health Service report on whistleblowing, Freedom to Speak Up? (February 2015,) by Sir Robert Francis QC, documented the retaliation that was mounted against staff in hospitals for reporting systemic problems, incompetence and medical errors that impacted patient safety. The report includes recommendations for a shift in culture to not only protect but value whistleblowers, and zero tolerance for retaliation.

Like whistleblowers in other fields, most healthcare whistleblowers say they would do it again even knowing what the consequences would be. Why would they engage in such high-risk behavior? A 2011 National Business Ethics report states that most whistleblowers are very committed to their workplace and they have been successful performers. An article by Vicki D. Lachman, Whistleblowers: Trouble Makers or Virtuous Nurses? (MEDSURG Nursing, April 2008,) bases whistleblowing in healthcare as driven by the ethics of the duty to tell the truth, the standards of professionalism (nursing Code of Ethics,) virtue, and that inexplicable courage that causes an individual to jump into harm’s way to safe the life of another. She also states that, “They (whistleblowers) are above average performers committed to the organization with a strong belief in moral principles.” Lachman however notes the potential retaliation:  “The list of negative consequences to whistleblowers seems endless: broken promises to fix the problem, disillusionment, isolation, humiliation, formation of an “anti-you” group, loss of job, questioning of the whistleblower’s mental health, vindictive tactics to make the individual’s work more difficult and/or insignificant, assassination of character, formal reprimand, and difficult court proceedings.”

The victimization of patients and the victimization of people on the inside of healthcare trying to save lives cannot be ignored. These tragedies are deserving of a hard look at where the bodies are buried, who is causing these deaths, and what needs to be done to protect whistleblowers so that when we access medical care we are not inadvertently boarding a plane destined to crash and burn.