new cover
“Patients are needlessly dying throughout the entire health care system, and not just in VA hospitals, but the larger tragedy continues to be ignored.”
Greenville, SC (PRWEB) June 03, 2014
“Department of Veterans Affairs Health Care System is highly dysfunctional, and far too often needlessly deadly,” says Dr. Ira Williams, patient safety expert, and author of Find The Black Box “and most of that system’s problems were recognized, and effectively dealt with over 30 years ago at Harvard. Unfortunately, the effective use of authority, accountability, and minimum standards demonstrated by the Harvard Medical School Department of Anesthesia (http://is.gd/9daZ8A) Standards for Patient Monitoring During Anesthesia at Harvard Medical School, Eichhorn, J.H., Cooper, J.B., et al., JAMA, Aug 22/29, 1986, Vol 256, No 8., have never become the life saving model throughout the rest of the health care delivery system that they proved to be at Harvard.”
Dr. Williams continues, “The nation that scientifically allowed Curiosity to land on Mars, (http://is.gd/PR27EJ) in 2012, and continue to send back data has a health care system that is clearly chaotic in every direction one might turn. Witness the fact that the latest estimate of needless hospital deaths (http://is.gd/GzKOg3) is quadruple the original 1990 estimate of such deaths (http://is.gd/LTnBli) a quarter of a century later. The current VA crisis is only further evidence of an entire health care delivery system that is unorganized, dysfunctional, too often needlessly deadly, and with no evidence of a solution.”
Dr. Williams has long considered that 1986 Harvard Anesthesia Department study to be one of the most important articles concerning patient safety in the entire health care literature. “Those department leaders demonstrated organizational structure, authority, accountability (nine separate hospital departments), and provided rapid, and effective improvement in patient safety resulting in countless lives saved during the past three decades.”
Dr. Williams says one quote from that article both illustrates its potential importance to patient safety, and indicts those who failed to implement its proven value. “They are fundamental minimal standards that would be achievable in the smallest rural community hospital.” Dr. Williams, in his continuing series of Open Letters (http://is.gd/wdU2CM) discloses how the fundamental patient safety measures instituted by the Harvard Medical School Department of Anesthesia demonstrated the demand for, and benefits from an organizational structure with clearly defined points of authority necessary for the achievement of patient care accountability, patient safety essentials clearly missing in the Veterans Health System, and throughout the entire health care delivery system.