Anesthesia Patient Safety

Jeffrey Cooper PhD

Remember when the biggest fear of dying in a hospital was the anesthesia?  We don’t hear about anesthesia deaths anymore – or at least not too much.  Maybe that’s because the Anesthesia PatientSafety Foundation was formed in 1985.  Through research and the sharing of information, advances have been made and lives have been saved.  Jeffrey Cooper PhD is the founder and Executive Director of the Center for Medical Simulation, which is dedicated to the use of simulation in healthcare.  He is also a founding member of the NationalPatient Safety Foundation and a colleague of mine on the board of governors of the NPSF for many years.

I remember years ago when I visited the simulation lab run by Dr. Cooper in Massachusetts.  I stood behind the glass and watched the physicians as they did “surgery” on mannequins.  The person behind the glass with me would make things go wrong so the anesthesiologist would have to find the problem.  I still remember that it was a mucous plug clogging the breathing tube.  The young physician couldn’t find the problem.  In this case, the patient would have died if it were real.  But it wasn’t real – no one died and I bet that doctor never made that mistake again.  This is what they do daily there – save lives through education in one very important area.

Dr. Cooper received the highest honor from his colleagues at the The American Society of Anesthesiologists, The Distinguished Service Award.  It’s my personal honor knowing him all these years and knowing what an impact he has made in safe patient care. Congratulations Dr. Cooper on this recognition.  I wish it could have come from me!

Who is Responsible for Patient's Safety

Your Telling it to The Choir

Dr. Bob Wachter wrote in his blog Wachter’s World about the recent conference in Chicago on diagnostic errors.  Dr. Mark Graber, a trusted physician and advisor to PULSE of NY for many, many years has been passionate about diagnostic errors in medicine since I have known him.  He founded the Society to Improve Diagnosis in Medicine.  The only thing I think Dr. Graber is almost as passionate about is disclosure to the patient and / or their family when something goes wrong. 

There are a few good, no great medical professionals like Dr. Wachter and Dr. Graber out there who are passionate about patient’s safety.   Some, because of their own experience and some because their fear that their number may be up soon.  With numbers like the recent study that there are as many as 400,000 deaths in hospitals due to preventable medical errors it seems to be only a matter of time that everyone will experience either an unplanned outcome to themselves, a friend or family member.

What I don’t get is why are there constantly conferences for medical professionals to learn better ways of doing things.  There is some improvement, but the focus needs to be more on the public.  When the public learns what WE are supposed to expect, we can start expecting no less. 

A recent program I did for the community of about 20 people brought together a mix of homemakers, business people and blue collar workers.  They were learning for the first time that things can go terribly wrong in hospitals.  I am careful to explain that for every “bad” thing that happens, there are thousands of good outcomes too.  But, would our government and medical societies be pumping patient safety money into a system that works?  I just fear it’s being pumped into the wrong place!

Here is something that can be done: Cautious Patient Communities

Jerod Loeb PhD

I Will Miss Him

A great man died today.  Jerod Loeb worked for the JointCommission.  He was the Executive Vice President for Healthcare Quality Evaluation.  A researcher, scientist, PhD, he was brilliant at his work.  But what made him most special was his humor, the way he explained things and way of speaking to me, a lay person at TJC, in terms and words I understood.  He was always sure to make sure I knew what he was talking about.  Funny and lively, Jerod was a brilliant, but very approachable and not in the least bit intimidating.

The last few years, even more powerful, he became a patient - openly fighting cancer.  He was gutsy enough, time after time to tell his audience, usually of medical professionals, what it was like to now be on the receiving end of sometimes questionable care.  Each time I saw him, he would have stories about his care.  He recorded the past few years on a website so his friends, colleagues and loved ones could follow along.

I didn’t see Jerod often, but I always knew he was someone I can count on.  He had a loyalty to the patients that the customers of the Joint Commission serve -  because he was one of us. 

Rest in peace Jerod.