Patient Safety Series Presenter Notes….2.11.25
Episode 1
Hello Healthcare Consumers and welcome to The Gary and Jay’s Healthcare Insider, the program that tries to help “Make healthcare easier to understand and navigate.” We are committed to making healthcare personal.
Today’s program: Patient Safety…….What all Consumers Need to Know
I’m Gary and I’m Jay and we will be hosting today’s program.
- We are not Clinical people.
- We are experienced in the Business of Healthcare with over 50 years of combined experience.
- We bring an Insiders view of how healthcare works.
- Our goal is to share our knowledge with consumers.
GP: Career in spans managing hospital and physician revenue cycle operations
that include:
Pt Admission, Precertification, Ins verification, billing and medical collections
JH: Chief Financial Officer for several large healthcare systems
Here we go with today’s program: Patient Safety
Patient Safety has seemingly become the unattainable Holy Grail for healthcare scholars, leaders, bureaucrats, politicians, physicians and executives. We have come to this conclusion because of the massive resources and efforts committed to the challenge and continued significant opportunities for improvement. There are as many definitions for patient safety as organizations focused on improving patient safety. For our purposes today, we’ll use the World Health Organization’s definition:
“Patient safety is the absence of preventable harm to a patient and reduction of risk of unnecessary harm associated with healthcare to an acceptable minimum.”
Because of the number of “Proverbial cooks in the kitchen” some argue this results in the numerous definitions, numerous focus areas, yearly goals and objectives and ever growing measurements. Or in other words a dilution of efforts and results. This is the second time we’ve focused our attention on patient safety because of a recent story covered by ProPublica concerning breakdowns in patient safety in a hospital in Montana. We’ll save details of the story for later and start with a very brief patient safety history lesson for the uninformed healthcare consumers.
Today, medicine is held in very high regard within American culture. (Even after the recent COVID situation.) The actual history of medicine goes back thousands of years. But we’re not going to go back that far. The genesis of much of Americans’ beliefs and thoughts about our healthcare system only go back as far as 1847, this marks the formation of the American Medical Association. At one time, this organization claimed the majority of physicians in the United States as their members. A significant document created upon their beginning was their Code of Ethics. The Code has been revised several times since its origination. The influence continues to modern day and is a significant contributor to how medicine is thought about. Despite the AMA membership is only a minority of today’s physicians. The AMA continues to exert significant lobbying power and continues to influence major healthcare legislation.
Depending upon your age, how you feel or think about healthcare might be different. For example, if you or your parents were born between 1930 and the 1950, you might be influenced by the subtle paternalistic nature encouraged by the AMA’s Code of Ethics. This is reflected in the expectation of patients’ obedience to physicians’ directions. It also contributed to a blind trust in the physician profession. An example of the historical relationship between physician and patient was portrayed in a 1957 revision to the Code of Ethics. This revision stated, “a surgeon is obligated to disclose all facts relevant to the need and the performance of the operation.” Today this is known as informed consent. And plays an interesting role in the aforementioned ProPublica story and the ultimate purpose of today’s program.
With this brief history, let’s now turn the clock forward to more recent times. Patient safety has had a rather dubious history in the United States. In 1999, the curtains were pulled back on the American healthcare system by the book To Err is Human. The book disclosed “somewhere between 44,000 and 98,000 unnecessary” deaths were occurring every year in US hospitals. We found the gap of 54,000 was unusually large for a science based industry and didn’t make much sense. Essentially little change occurred in patient safety after the books publication. Along with 20/20 hindsight and some of our own research, we discovered the activities addressing patient safety after the book appear to have been very episodic, random and seemingly ineffective. Aside from the obvious, a concern within the medical community emerged that an unintended danger and consequence of the book could be a loss of confidence in the medical profession. We’ve concluded the impact was marginal.
Ironically, as we dug deeper into the history of patient safety, we discovered a major factor impacting patient safety was the advent of the Internet. You might wonder How? Until the internet and mobile devices, a patient’s medical information was asymmetric. This means medical information was completely controlled by the physician and the hospital. At the time, no one completely understood how significant the impact all this would have on the democratization of medicine.
The results from these findings was an explosion of resources within the government, the physician community and healthcare organizations to upgrade patient safety. Which leads us to the ProPublica story Eat What You Kill, December 4, 2024 that motivated us to do this story.
This is a complex story involving many breakdowns in patient safety systems ultimately resulting in patient harm and patients’ deaths. We’ll not reproduce the story here but encourage you to go online and read it for yourself.
Ironically, corresponding with the ProPublica story a family friend was given a diagnosis potentially requiring minor surgery to remove “potentially” small malignant tumors her physician had been monitoring for over 15 years. Based upon our friend’s research and consultation with her physician, the diagnosis and recommendation for surgery were all confirmed based upon her research. Except for one small detail. Before having the surgery, our friend asked her physician about having the tumors biopsied. He indicated this wasn’t necessary and wasn’t going to do it. Being strong-willed, she found another physician to perform the biopsies. The biopsies were done, indicated the tumors were benign and no surgery was necessary. Great news, right? Well, she returned to her original physician, shared the good news and was treated like a petulant adolescent ignoring parental advice. To make matters worse, while in her original physician’s office, he decided to call the new physician and fortunately she was with a patient and didn’t take the call so he left a message and we’ll end the story here. So in 2025, physician behavior more prevalent in the 60’s is still alive and well.
This is going to be a three episode story. Our next segment will involve an experienced nurse to share real life patient safety situations she’s encountered. We’re doing this to help build context for having a detailed, resource guide to use when dealing with physicians and hospitals.
TAKE AWAYS
HCNC is your healthcare partner that offers healthcare consumers information to navigate the healthcare maze via our website.
The program and take away information of the program will be available on our website www.healthcareconsumernavigatorcenter.com.
Our next topic will be:
This concludes our program OUR FIRST PATIENT SAFETY EPISODE, and we hope the program explained PATIENT SAFETY and has answered some of your questions.