Beware the Grieving Warrior

Beware the Grieving Warrior: A Child's Preventable Death. A Struggle for Truth, Healing, and Change
Larry Hicock with John Lewis

"This book is a riveting read not only because of its heart-wrenching outcome and local characters, but because of its potent topicality: According to data collected from Britain, Australia and the U.S., an estimated 10,000 Canadians die in hospitals annually as a result of medical error, another 10,000 from incidents like hospital infections and unexpected drug complications. It's something we always hear, but due to a naive trust in our medical system, rarely put into action: You are your best advocate."
- Hamilton Magazine

In early 2003, Ontario's deputy chief coroner ordered an inquest into the tragic deaths of two children due to post-operative complications in a Hamilton hospital. The cases may never have been reported were it not for John Lewis, a registered nurse, and father of 11-year-old Claire -- one of the two children.

Beware the Grieving Warrior describes John's fight, in the midst of immeasurable grief and sorrow, against hospital staff and administration who failed to acknowledge their neglect. By turns shocking and heartrending, infuriating and inspiring, this book offers a chilling first-hand account of the obstacles and resistance Lewis encountered as he wound through a hellish maze of bureaucracy, until he won his day in court. The story is intensely intimate and brutally honest. It is about the suffering that inevitably results -- for patients, their families, and for the health care professionals involved -- when the truth is withheld.

At Amazon
http://www.amazon.com/Beware-Grieving-Warrior-Preventable-Struggle/dp/1550226738
At ECW Press
http://www.amazon.com/Beware-Grieving-Warrior-Preventable-Struggle/dp/1550226738
As eBook
http://www.diesel-ebooks.com/cgi-bin/item/1554906733/Beware-the-Grieving-Warrior-A-Child's-Preventable-Death-A-Father's-Fight-for-Justice-eBook.html

CMAJ - Apology marks new era in response to medical error, hospital says
http://www.cmaj.ca/cgi/content/full/168/6/757

Grieving father John Lewis says there are no "real winners" in this case
http://www.cmaj.ca/cgi/eletters/168/6/757#273

Patient Beware
http://www.readersdigest.ca/mag/2004/06/patient.html

CMAJ: Medical errors, apologies and apology laws
http://www.cmaj.ca/cgi/content/full/180/1/11

Articles by J.E. Lewis at NIH
http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=search&db=pubmed&term=Lewis%20JE%5Bau%5D&dispmax=50

Doctors find confession is good for the soul
http://www.rd.com/living-healthy/doctors-confess-their-fatal-mistakes/article185422.html

The foundation established in memory of Claire Lewis is called Revolution Hope.

The Blindmen and the Elephant

by John Godfrey Saxe

It was six men of Hindustan
To learning much inclined,
Who went to see the Elephant
(Though all of them were blind)
That each by observation
Might satisfy the mind.

The first approached the Elephant
And happening to fall
Against his broad and sturdy side
At once began to bawl:
"Bless me, it seems the Elephant
Is very like a wall".

The second, feeling of his tusk,
Cried, "Ho! What have we here
So very round and smooth and sharp?
To me 'tis mighty clear
This wonder of an Elephant
Is very like a spear".

The third approached the animal,
And happening to take
The squirming trunk within his hands,
Then boldly up and spake:
"I see," quoth he, "the Elephant
Is very like a snake."

The Fourth reached out an eager hand,
And felt about the knee.
"What most this wondrous beast is like
Is mighty plain," quoth he;
"'Tis clear enough the Elephant
Is very like a tree!"

The Fifth, who chanced to touch the ear,
Said: "E'en the blindest man
Can tell what this resembles most;
Deny the fact who can,
This marvel of an Elephant
Is very like a fan!"

The Sixth no sooner had begun
About the beast to grope,
Than, seizing on the swinging tail
That fell within his scope,
"I see," quoth he, "the Elephant
Is very like a rope!"

And so these men of Hindustan
Disputed loud and long,
Each in his own opinion
Exceeding stiff and strong,
Though each was partly in the right
And all were in the wrong.

So oft in theologic wars,
The disputants, I ween,
Rail on in utter ignorance
Of what each other mean,
And prate about an Elephant
Not one of them has seen!

Has your doctor or medical team seen and read your ENTIRE file?

NYT: When patient handoffs go terribly wrong

"Handoffs are supposed to mitigate any issues that arise when doctors pass the responsibility for patient care to a colleague. “But that requires investing time and effort,” Dr. Arora said, “and using handoffs as an opportunity to come together to see how patient care can be made safer.”

Most of the time, however, handoffs are fraught with misunderstanding and miscommunication. Physicians who are signing out may inadvertently omit information, such as the rationale for a certain antibiotic or a key piece of the patient’s surgical history. And doctors who are receiving the information may not assume the same level of responsibility for the care of that patient. “Handoffs are a two-way process,” Dr. Arora observed. “It’s a complex interplay.” Missed opportunities to impart important patient information result in more uncertainty for the incoming doctor. That uncertainty leads to indecision which can ultimately result in significant delays during critical medical decisions."

Proper assessment and diagnosis should not be rushed through like a Triage situation. When your "specialist" sees you without having read your record and for a mere 15 minute consultation - as per "hospital policy" - your life can be ruined.

Article here

Tyee: To Save Big Health Dollars, Put Doctors on Salary

A Canadian nurse says that to reduce medical costs and waste, we need to put doctors on a salary. Link

"As a retired nurse who has seen first hand the health system's inner workings, I propose a different reading of rising costs, and a different way to cut them:

Let's take the business out of medicine and put the doctors on salary.

I offered this same advice last year when the provincial government conducted a "Conversation on Health" survey, during which many people voiced their opinions and solutions. Here is my logic.

Pulling in patients

The Ministry of Health itself points the finger at the rising costs of rates paid to physicians and the increased usage of lab and x-rays services. Such costs rose by a whopping seven per cent in 2007, and have continued to escalate at an alarming rate.

Having worked in a medical clinic, I saw the physician spend an inordinate amount of time and energy figuring out how to get paid more from MSP. It seemed to me that if the business were removed from his practice, his time would have been spent practicing medicine, and everyone would benefit from it.

Needless to say, my voice is barely a whisper in the grand scheme of things. We need someone who has the courage and vision to face down the Canadian and American Medical Associations and save our health care system from extinction. Where is Tommy Douglas when we need him?"

Why is health care so hazardous? What needs to be done to improve safety?

Statement of Lucian Leape, M.D.
Member, Quality of Health Care in America Committee
Institute of Medicine
Adjunct Professor, Harvard School of Public Health

Concerning Patient Safety and Medical Errors

Before the
United States Senate
Subcommittee on Labor, Health and Human Services, and Education

January 25, 2000

"Good morning, Mr. Chairman and Senator Kennedy, and members of the committee. My name is Lucian Leape and I am a faculty member at the Harvard School of Public Health. I practiced as a pediatric surgeon for much of my career, but in recent years have focused my attention on research into medical errors. I am here today representing the Institute of Medicine's Committee on the Quality of Health Care in America which recently released the report To Err is Human: Building a Safer Health System.

In my testimony today, I will address two questions: 1) Why is health care so hazardous? 2) What needs to be done to improve safety?

Why is health care so hazardous?

Findings from several studies of large numbers of hospitalized patients indicate that each year a million or more people are injured and as many as 100,000 die as a result of errors in their care. This makes medical care one of the leading causes of death, accounting for more lost lives than automobile accidents, breast cancer or AIDS. While these findings are not new, and some hospitals have improved their error reduction activities, clearly a much greater effort is needed to make health care safe.

No physician or nurse wants to hurt patients, and doctors, nurses, and other health workers are highly trained to be careful and take precautions to prevent mistakes. They are held and hold themselves to high standards. Paradoxically, it is precisely this exclusive focus on the individual's responsibility not to make mistakes, reinforced by punishment, that makes health care so unsafe.

The reason is that errors are seldom due to carelessness or lack of trying hard enough. More commonly, errors are caused by faulty systems, processes and conditions that lead people to make mistakes. They can be prevented by designing systems that make it hard for people to do something wrong and easy to do it right. Safe industries, such as aviation, chemical manufacturing, and nuclear power, learned this lesson long ago. While insisting on training and high standards of performance, they recognize these are insufficient to insure safety. They also pay attention to factors that affect performance, such as hours and work loads, work conditions, team relationships, and the design of tasks to make errors difficult to make. They create safety by design. Health care must do likewise.

Approaches that focus on punishing individuals instead of changing systems provide strong incentives for people to report only those errors they cannot hide. Thus, a punitive approach shuts off the information that is needed to identify faulty systems and create safer ones. In a punitive system, no one learns from their mistakes."



Link

"To get the best care, you have to go out and get it"

he desire to be seen as a person is a common complaint among cancer patients caught in a system that seems overwhelmed by waiting lists and swamped by test results, where phone calls tunnel through to voice mail and a busy doctor may have mere minutes to explain the most complicated, heart-stopping medical information.

Lynda Coghill recalls how her doctor barely spared a few seconds to deliver a curt death sentence. The Newmarket, Ont., school teacher was diagnosed with ovarian cancer at 39. At an appointment after surgery and radiation, she told her oncologist she was still bleeding. He did a quick exam, announced she had a new tumour, and said bluntly: “Your chances are slim to none.” He told her to wait a few weeks for the results of a biopsy, then left to treat a patient down the hall.

“I looked at the nurse in sheer disbelief,” Ms. Coghill says. “The doctor had proceeded to tell me, in less than 30 seconds, that I was going to die. He didn't seem to care that I had three small children.”

She cried for days, unable to eat or sleep. She and her husband planned her funeral. At last, she contacted the sympathetic nurse from the doctor's office and persuaded her to call for an “unofficial” biopsy report. The tumour was benign. Eight years later, Ms. Coghill remains angry about having been treated “like a numbered object on an assembly line.”

To get the best care, patient advocates say, it's not enough to wait passively in an appointment room. You have to go out and get it.'

From The Globe and Mail - Link

This article does not, we think, apply just to cancer patients...and it is telling that physicians dread falling ill, because then they would be cast in the role of... patients.

From the drama/film WIT with Emma Thompson. This patient was too good, and paid the ultimate price.
It's good to be patient - but not too patient...

Illuminations from THE RUNAWAY BUNNY by Margaret Wise Brown.