Lucian L. Leape

Chapter 21 in: L. L. Leape, Making Healthcare Safe

Despite encouraging progress in the early years of the patient safety movement, it soon became evident that there were deeper issues that needed to be addressed. We realized that we were not going to make health care safe by making process changes one by one, even powerful changes such as eliminating CLABSI or implementing the surgical checklist.

For the second Global Patient Safety Challenge, the WHO chose making surgery safer. My involvement was minor. One day, a year or so after the hand hygiene program started, I received a call from Pauline Kelly, my friend from the Reporting Guidelines project. The World Alliance leaders had decided to do a Patient Safety Challenge on a surgical topic. This made good sense, since surgical mishaps were well recognized as a major cause of mortality worldwide. Nearly half of all AEs discovered in the Medical Practice Study were related to a surgical operation. She asked me if I thought Atul Gawande would be willing to lead it.

Where was the World Health Organization on patient safety? Patient safety was taking off in the USA and the UK, and there were stirrings in Canada, Australia, Denmark, Spain, and a few other European countries, but what about the rest of the world? What about developing countries? With fewer resources, their needs for attention to medical harm might well be even greater.

“The doctor treats me like an idiot.” “He doesn’t like people who ask questions.” “He makes me feel like I’m wasting his time.” (from a patient)

“Publish or perish!” The governing principle of academia. Trite though it may be, true it also is. At any research university—and that is where medical schools are and where those who do research in patient safety work—you do not get promoted if you don’t publish.

On March 5, 1984, Bennington College freshman Libby Zion died at New York Hospital. She had been admitted the night before with vague symptoms and strange jerking motions. After consulting with her family physician, the residents on call gave her intravenous solutions for possible dehydration and prescribed meperidine to control her jerking motions. They then left to take care of other patients. Luise Weinstein, the first-year resident, was responsible for 40 other patients. No sleep for her.

When patients are harmed by their treatment, they want three things from their doctor: they want the doctor to tell them what happened, say they are sorry, and tell them what will be done to keep it from happening to someone else. “What happened” is an acknowledgment that something went wrong, followed by an explanation of why it happened, and some guidance on what the future holds. If they have additional medical expenses or a disability, they also want compensation. Sadly, none of this happens most of the time [1].

Gwyneth Vives, a scientist at Los Alamos National Laboratory in New Mexico, suffered a complication and bled to death 3 hours after giving birth to a healthy boy in 2001. It was 4 days before Christmas. Vives suffered a vaginal tear and other lacerations during the delivery that caused profuse bleeding. Her obstetrician, Pamela Johnson, was sued for failure to order a blood transfusion for Vives as well as abandonment since she had turned over repair of the vaginal tear to a midwife. Two other patients also sued Johnson. Jean Challacombe alleged that Johnson tore her bowel and uterus while doing a dilation and curettage the same day Vives died. Tanya Lewis accused Johnson of doing an unnecessary hysterectomy.

On March 30, 1981, Ronald Reagan, president of the USA, was shot in an assassination attempt. During his lifesaving surgery at the George Washington Hospital, the nation was riveted by the clear and calm account of its progress by the hospital’s physician spokesman, Dennis O’Leary. Five years later, O’Leary became the head of the Joint Commission on Accreditation of Hospitals.