In 2004, a patient was killed by a mix-up during a routine procedure. Rather than conceal the error, the hospital’s leadership openly discussed the patient’s death. “You can’t understand something you hide,” the patient safety officer had explained. The move galvanized a campaign to become the safest hospital possible. As we waded through the stillness of a clinic strangely devoid of patients waiting, phones ringing, and pagers interrupting, my guide described the response to that patient’s death. “We have a saying here, ‘If you lose the patient, be sure you don’t lose the lesson.’”

I came to learn how to make health care safer. The journey was set in motion a year before, during my third year surgical clerkship. Maggie, a 76-year-old grandmother, whose kind eyes belied her years as stern matriarch of her family, came to the emergency department short of breath. She was just in time: her electrocardiogram showed torsades des pointes, a heart arrhythmia that even a medical student can spot from across a room, for its distinctive, tornado-shaped pattern and well-known lethality. The ED team stabilized Maggie’s heartbeat. Another crew remedied the underlying problem – a dead pacemaker battery. Quick, skillful action saved Maggie from the brink of catastrophe, but the victory was short-lived.

Maggie grew anxious, her pulse quickened, and her blood pressure sagged despite bolsters of fluid. A scan found a bleed in her abdomen. We gave blood, clotting cells, to no avail. Maggie’s body grew bloated from the infusions, restricting her breathing; even with a ventilator, her lungs couldn’t get enough oxygen. A decision was needed – a tough one – and we located Maggie’s loved ones. The family meeting was raw: Screams. Tears. Frantic phone calls. Sobs. Prayers. That Wednesday afternoon in the ICU, our boldest hope was that Maggie might be able to say goodbye.

I decided to present the case to classmates and was shocked by what turned up in Maggie’s chart. The cause of her bleeding was identified as a rare but well-known complication of a blood thinner. Intended to prevent clots, it had precipitated an immune attack on her ability to patch small bleeds. The complication, heparin-induced thrombocytopenia (HIT), occurs in up to 1 in 20 patients with a medical history like Maggie’s. It was predictable – was it preventable? Deep within the phonebook-sized chart, I spotted a hasty note, scrawled days before Maggie’s death, “?Platelets – consider work-up for HIT syndrome.”

The critical recognition never got from the chart to my team. We did not complete the work-up in time, and Maggie perished as a result. Feeling sick, I rushed out of the sub-basement records room, unsure of what to do with this information. I was shocked that our team – that I – had failed Maggie. Worse, I felt as if my chosen profession, a calling based on helping patients, had betrayed me.

Finding meaning in Maggie’s case took time and another mistake, this time a benign one. I booked a flight for the wrong day and, arriving early to an empty convention, wandered into a symposium on patient safety. As we discussed sources of medical error, Maggie reappeared. “Every system is perfectly designed to achieve exactly the results it gets,” the lecturer, a pediatrician from Boston, explained. The hairs on my neck stood up. Maggie’s was a case of predictable human error – a lost communication – within a system that failed to catch the mistake. The answer was not to replace us with a smarter, more experienced team, but to implement a system to mitigate our fallibilities.

A few months after the symposium, I left medical school for a yearlong fellowship in Washington, DC, with the American Medical Student Association. I was initially drawn to the opportunity to be involved in the health care reform push, but as I began my job, I couldn’t imagine ignoring patient safety. I took a risk and rewrote my entire work plan. I developed a patient safety platform to attract activist students to the cause. The WHO Surgical Safety Checklist seemed ideal, and visiting a dozen campuses and conferences, I urged students to become checklist leaders. I designed a symbolic pin for their white coats and a free checklist “app” for their iPhones. That September, I connected with an international team of students, and we convened in Boston to create a campaign we named “Check a Box. Save a Life: The first global student sprint to improve health care.” We launched the effort with live online speeches from Drs. Don Berwick and Atul Gawande, leading proponents of patient safety, particularly through the checklist. To our excitement, the broadcast drew a crowd of 1,400 students in 11 countries. This audience went on to spark change at dozens of campuses. One participant, a Chicago medical student, won checklist implementation across his entire hospital system.

“Check a Box. Save a Life” proved students could be safety leaders, and I wanted to understand where we could apply that leadership. After seeing what improvements were possible, I became determined to focus my career on improving health care. To this end, I have taken another detour from medical school, to study public health and health care management – including quality improvement – with the goal of gaining the analytic and leadership skills I need to be an effective physician-improver. After medical school and residency, I intend to reinvigorate field of primary care by improving quality, safety, teamwork, and value. Maggie continually reminds me of the urgency of learning our way to better, safer health care and the stakes of failing in this pursuit. I lost the patient, but I will carry on the lesson.

| Read Next Essay

Having come from an institution where teamwork and safety measures are boiled down to a science, I was shocked that the physician had tried to run a complicated code requiring a series of tasks and steps as a solo operation. He had effectively silenced his team through his unilateral relationship with the nurses. He was frazzled, disorganized and agitated. These emotions were a strong reflection of the commitment he made to his patients, but his actions and the ensuing team dynamics compromised patient safety. The patient didn’t receive prompt resuscitation and treatment, suffering negative outcomes as a result.

I would not have imagined that patient safety would take center stage on my three month long rotation in Central Africa. In dissecting the situation that unfolded with the child, I identified two points that endangered the safety of the patient. First, the kit was incomplete and not properly prepared. Second, the doctor exercised a breed of medicine that silenced his team and marginalized important players that could have positively impacted this unforeseen event. I set out to take the first steps toward creating a culture of preparedness and open communication in order to improve patient safety.

I talked to other students, nurses and staff at this hospital in regards to my problem. It was clear that measures to improve patient safety would be met with a great deal of resistance. At the epicenter of the problem, the traditional culture of medicine in which the physician handed down orders was incredibly restrictive. The physician was overburdened with clinical decision making, procedures and patient care. He was on call 24/7 and quite frankly, worked to the brink of exhaustion. The rest of the staff often had some downtime, but since these were times during which they hadn’t received direct orders they were content to lay low. Moreover, since the nurses had such a low level of autonomy I perceived them as taking less stake in their patients. My suspicions were confirmed when I asked them directly. Their efforts would be futile given that they were constantly micromanaged.

The goal was to open the lines of communication among the team members to optimize the working environment to benefit patient safety. While the doctor was not convinced by the proposed changes, he was incredibly astute in recognizing the points at which the lines of communication had broken down, as were the nurses. The problem was not a lack of awareness of their behavior. Instead, there was a lack of an external and supervisory source authorizing each team member to have a particular predefined role. We organized a meeting and allowed a certain level of autonomy congruent with a nurse’s training, experience and skills. This worked mainly to empower the various team members of taking stake in their respective roles and speaking up while allowing the physicians to attend to their proper clinical role.

The second goal was to improve general preparedness. As illustrated by the mask episode, resource availability is not only about ordering and receiving the medical devices, instruments and medications, it is about finding them in a timely manner to efficiently put them to use when needed. Unprepared, it was impossible to efficiently put them to use. We split up the medical equipment into various subcategories. We then assigned one nurse to be in charge of making sure items in his or her division were in their proper place and that enough of a supply existed. We created a checklist of the most important items and the stockpile. On a weekly basis, another member of the team would have to go through the checklist. In essence it was a circular reporting system where everybody on the team had to report to another at the same level. Micromanaging orders were not coming from above. While preparedness improved, there were pleasant surprises that emerged as well.

Our simple measures improved the lines of communication and preparedness in the hospital. Moreover, there was a shift in the culture of safety that carried with it far reaching implications. As necessary decisions were shifted onto other members of the team, we found them to take much more ownership in their patient care. Over time the physician seemed less tired and burned out. The lines of communication had also opened up considerably. Team members were more attentive to mistakes. The team’s enthusiasm for asking questions and increasing their medical knowledge also flourished. While the changes were subtle, the environment we worked in took major advances in building a culture of safety.

As I reflected on my experience, it bewildered me to think that such cost effective and beneficial measures did not play a greater role in health care development and global health. In addition to increasing patient safety, these measures had myriad downstream effects that promote a better work environment, open the lines of communication and decrease physician burnout. Investing in patient safety promises to dramatically improve healthcare delivery in resource poor areas. Through concrete as well as intangible elements, a new culture of medicine will flourish. Patient safety improvements need to be carried out with equal fervor in the developing world as they are now here in the US. Only by addressing this pivotal area of medicine will we be able to optimize the vast commitments to global health that we have already made.

| Read Next Essay

As things were wrapping up, the new mother began to complain about feeling warm and she appeared a little flushed. The doctors and nurses didn’t think it was too concerning, so they decided only to monitor her. Within minutes, she complained of nausea and minutes after that difficulty breathing. Less than ten minutes after her initial complaint of feeling warm, a resident was performing CPR on the patient while a code team was called.

When the patient was transferred to the intensive care unit, she had a serum magnesium level of 22 mEq/L.

The series of events that lead up to the patient’s cardiac arrest began in a boardroom. A decision was made to reorganize the layout of premixed IV medications in the Ob/Gyn ward. Previously the IV bags were arranged by drug, the decision was made to reorganize them by size. This lead to the one-liter bag of Pitocin being placed right next to the one-liter bag of magnesium. Changes to hospital policies and procedures are common, and should not provide difficulties to patient care, except in this instance; the change was never communicated to the staff. None of the doctors or nurses that evening knew a change in medication lay out was occurring.

A single misstep usually does not lead to patient harm; the system should have many fail-safes built in, but they were not evident that day. For easy distinction, the Pitocin bag was to have an additional bright green sticker while the magnesium back was to have a bright pink sticker. On the day of the incident, the only labeling the doctors and nurses saw was the black text on white background of the Pitocin and white text on black background of the magnesium.

Despite all of these failures, had any member of the staff checked the label before administering the drug, the adverse event could still have been prevented. The nurse administering the drug later recounted how routine it was… she has done this a million times before, so she just grabbd an IV bag from the same old spot and hung it and went about her remaining duties.

While the patient was coding, the team had tremendous tunnel vision. Protocol was yet again not followed, not a single person looked at the IV pole to double check what was hanging. The attending thought it was an amniotic fluid embolism, the team followed his direction. It was not until the patient was in the ICU and blood tests came back, that we even realized the patient had magnesium toxicity.

After the event, the hospital played the shame and blame game, and tried to brush all of it under the carpet. The only open and honest discussions were whether to even tell the patient about the events surrounding the incident and whether to fire the nurse that administered the medication or not. There was no debriefing of the staff. None of the attendings, residents or medical students were queried regarding the events of that evening by hospital administrators. The only quality improvements measures were done internally within the Ob/Gyn silo, with no contribution from nursing or pharmacy.

The nurse who administered the medication has been working in the unit for many years and is very well liked. She broke down in front of the attending that evening, sobbing, asking how she could have been so careless. Those present did their best to comfort her, but there was no other care for the providers. She heard people openly discussing whether or not she would be fired from her job.

I will always carry the pain that the patients’ family and the nurse who administered the medication for the rest of my life. I believe it all starts with open and honest communication, not only between the patient and providers, but also between the different silos within the hospital. To that end I have been working with other health professional students to create an interdisplinary leadership series. The goal is to break down the silo early in the careers of health care providers. Medical, nursing, public health, applied health and pharmacy students mingle and participate in joint activities with hopes that the cooperation will be carried into their practices.

Open disclosure after an adverse event is my true passion, though it is not enough. The information we gain not only needs to be disclosed to patients, but also used for quality improvement purposes. I am currently working with the Institute of Patient Safety Excellence at UIC on the 7 pillars grant. The institute is taking the combined full disclosure and quality improvement model from UIC and implementing it at multiple hospitals in the Chicago area.

This event has instilled in me a passion and a drive to always be open and honest, whether it is with my patients or with my fellow providers. I believe it is only a first step, but it is a giant step if everyone in the healthcare profession can take it to heart. I hope to be part of a generation of health care providers who will work together to instill a patient safety culture across the field of medicine.

| Read Next Essay ]]> http://npsfcongress.org/young-physicians-essays/firstessay/feed/ 0 http://npsfcongress.org/young-physicians-essays/essayfour/ http://npsfcongress.org/young-physicians-essays/essayfour/#comments Thu, 30 Jun 2011 20:01:06 +0000 admin http://npsfcongress.org/?p=1167 The smiles of optimism seemed to glow even more in the warmth of the sun on that cloudless and memorable day. As I looked out at the rest of my medical school class, it was clear that we were each filled with a plethora of vibrant and diverse emotions. Chief amongst my own was simply being proud of what we, as a collective group, had accomplished. It was graduation day. It was a day where we stood, after four years of intensive study, fully knowing that the personal sacrifice that had been required was easily worth the experiences that we now shared. Our atmosphere that day was undoubtedly one of optimism, one that would carry through to our imminent internships and on through our medical careers.

We did find, however, that internship greeted that optimism harshly. Being overworked and overextended became more common than I had prepared myself for. I often found myself placed in situations where I was not ready, had minimal related training, or was in a state of fatigue that enabled only the coordination necessary to keep myself upright. One such instance that I have reflected greatly upon occurred in the Medical ICU.

It was already long into the evening when Tony and I heard that we would be getting another transfer from an outside hospital. It had felt like we were swimming upstream for most of the day and into the evening, as the constant stream of ICU patients kept coming from our ER. We had been keeping the pace up thus far, but 0200 is about the time you start to feel the pinch during the 30 hour shift. We knew this new patient was about one hour out, so Tony encouraged me to try to use the time to get some sleep in before they got there. Knowing how poorly I function at hours 24 to 30, I took him up on his offer. Unfortunately, the pages to look after our current patients kept coming steadily at about 15 minute intervals. It made trying to sleep frustrating enough wherein I gave up and just did another set of walk rounds on our patients. It was at this time when our last transfer patient arrived. She had been billed to us as “respiratory distress, hypotension” of unknown etiology. As she came in, we could see that her mental status was depressed, she had a thready palpable femoral pulse, and she was struggling to breathe. We ordered a salvo of basic labs, got an x-ray, and started our first fluid bolus to try to increase her blood pressure. From here, things progressed very steadily in the wrong direction and in a manner that seemed almost completely out of my control. Despite our basic resuscitative efforts, she continued to deteriorate. We had to start IV pressors to attempt to artificially increase her blood pressure. Shortly later, we realized she was going to need to be intubated because her work of breathing was continuing at such a constant and unsustainable level. As Anesthesia came for intubation, she suddenly went into an arrhythmia and coded on the table before us. At this point, it was about 0630 and our attending was just arriving in to get ready for rounding. His arrival timing was crucial. Well rested, knowledgeable, and experienced, he helped us through the code until we managed to again get a normal sinus rhythm beating from our patient’s heart.

As we started getting data back and went through information, our attending realized that our patient’s clinical picture and lab work fit best with a prolonged, untreated asthma attack. At the moment she said that, I distinctly remember how all the blocks finally fell into place. It made the most sense, and it would have potentially been easily treated by a continuous nebulizer treatment. We hadn’t picked up wheezing on physical exam, but this was simply because she had progressed so far along that she was not moving enough air back and forth for the wheezing to be produced. We knew about that caveat to prolonged asthma attacks, we had learned about it in medical school, and had circled the correct answer on countless multiple choice tests. However, in the fog of our sleep deprivation, it had not yet made it into our consciousness. At the end of this event, it was abundantly clear that our interpretation of results and clinical findings, our development of differential diagnoses, and our application of treatments were all greatly slowed and affected by our fatigue.

Reflecting upon this incident is impossible to do without again acknowledging that atmosphere that we had on graduation day. I remember, during the long hours of that night, not only wondering how much patient care was suffering, but also how it was causing that initial optimism I had carried through medical school to invariably fade. Being overworked and underprepared is one thing, but being put in a difficult situation while simultaneously being forced to take the massive handicap of being awake for close to thirty continuous hours was an incredibly disheartening experience. I knew I could do better, and I knew we were not doing everything we should, or could, for this patient. Like all others, this was a patient who had a unique life, a unique story to tell. Doing her the disservice of having someone awake for so long directly responsible for her life seemed nearly impossible to accept. I kept wondering if we would ever have an airline pilot working 30 continuous hours, or a bus driver, or a ship’s captain. I do know that medicine is costing increasingly too much, and that there is no foreseeable money in the Medicare budget to expand residency programs to a point where this situation would not be mandatory. However, it does seem impossible to internally justify having our physicians work for 30 hours at a time without the opportunity for sleep. Having experienced it, I am forced to submit that the quality of care necessarily plummets as the 2nd morning approaches and passes. The mistakes made during those hours are some of the most frustrating, as they are largely needless and avoidable. Being helpless at the hands of fatigue and being forced to face the complexities of modern clinical care at that time represented the most consequential detriment to patient safety that I have experienced in my medical training thus far.

It is with stories like these that I hope it becomes easier to understand and to justify the necessity of official limitations on work hours, and their honest enforcement, for physicians in training. The changes set to begin in July 2011 will help, as the maximum hours go from 30 to 28 for upper level residents. It does not seem like much, but it certainly brings us one step closer to being capable of providing safe and effective clinical care at all hours of a hospital’s operation. It goes without saying that stories like this one are abundant in academic centers around the country. And it is necessary for us as a medical community to begin to acknowledge them openly and accept that they do occur. It is with this acknowledgement that we can move forward with changes that put patients less at risk of sleep deprived errors, but still maintain the rigor we know is necessary in residency training.

| Read Next Essay

A surgeon, army veteran, and personal mentor once said to me, “Lots of people call doctors ‘heroes,’ but patients are the real heroes because they undergo anesthesia, they let someone open them up—they take the risk.” For surgical patients, risk is clear and present. For medical patients as well, however, lingering in a hospital opens the door to nosocomial infections. My mentor’s words remain with me as a tool to empathize with patients, to appreciate the risks they take in pursuit of healing. Not two months after he said them, my mentor’s words were made even more poignant when he inadvertently removed a patient’s kidney while performing another operation.

Despite the best intentions of health care professionals, patients often take real risks at the same time as they seek treatment. In this case, a middle-aged woman planned to have the lower part of her colon removed because of recurrent sigmoid diverticulitis, a condition in which weakening of the colon’s walls causes infection. At the outset of the procedure, the surgeon called a “timeout,” during which he repeated the patient’s full name as well as the procedure and side it was to be completed on. Everyone present in the room, including the surgeon, surgical resident, nurse anesthetist, surgical technician, circulating nurse, and two medical students, had to agree that they were about to perform the correct procedure on the correct patient. Some said, “I agree,” while others nodded their assent. With that, the surgeon made the first incision.

The procedure proceeded as planned until the surgical resident noticed something unusual in the patient’s pelvis—a mass of tissue that bore an alarming resemblance to a tumor. A flurry of questions filled the room: What was the mass? Cancer? If so, what should they do? Take the mass out now, or make the patient undergo another operation and round of anesthesia?

Together, the surgeon and surgical resident agreed that the mass was worrisome enough to warrant biopsying and likely removing it. They would explain their choice to the patient after the procedure. As is the approach to many types of cancer, they decided to biopsy a small part of the mass and send it to the pathology lab for identification before removing it. After the biopsy, they had little to do but wait. As the time allotted for the procedure elapsed, pressure to do something began to mount; the operating room was needed for another surgery, while the surgeon and resident were needed for other cases. Under these conditions, they decided to act.

While surgeons train for years to make decisions under pressure, enough pressure has been shown to make anyone a poorer decision maker. Before the biopsy results came back, the surgical team decided to move forward and remove the unidentified mass. It was a surprisingly easy procedure. For one, the mass appeared to possess a stunted blood supply, meaning it could be removed without much blood loss. In addition, the mass was encapsulated, as many cancers are, leaving it free to separate from the healthy tissue around it. When the mass was fully excised, the resident placed it on a table and cut into it, revealing glistening glomeruli: the unmistakable architecture of a kidney.

The first thing the surgeon did was explain to the patient’s family what had transpired. He described, as he later would in his operative note, how kidneys are rarely found so low in the pelvis, how atrophied the kidney appeared, and how these and other factors contributed to the mistake.

In the midst of feeling grief for the patient and her family, I contemplated how to approach this case and others like it to ensure that they did not occur. After doing some research, I concluded that wrong-site/wrong-surgery cases provided an instructive background for root cause analysis of this situation. For example, the Joint Commission’s Sentinel Event reviewers have identified factors that contribute to an increased risk of wrong-site surgery, many of which apply to this case. For instance, emergency cases have an increased risk for mistakes. While this case may not truly have been an emergency, the surgeon felt that the presumed pelvic mass was life-threatening and warranted immediate removal. The risk is further increased when multiple procedures are conducted on the same patient during a single trip to the operating room. This point is particularly salient in this case because not only were multiple procedures performed on the patient, but the mistaken procedure was unplanned. In addition, unusual time pressures increase risk. Perhaps most importantly, poor communication among members of the surgical team increases risk. This was definitely a factor because the surgeon proceeded to remove the presumed mass before pathology reported the results of the biopsy, which ultimately showed distinctly renal structures.

After performing this research, I felt duty-bound to write up my findings and submit them to the hospital administration along with an idea for how to avoid such tragic events. I encouraged the hospital to codify and adhere to a policy regarding the performance of unforeseen procedures on a patient under anesthesia who has not consented to the new procedure. Especially in situations that are not immediately life-threatening, I suggested that a second, intra-operative timeout could be performed related to the new procedure. In addition, improving communication and requiring that surgeons wait for pathology reports before proceeding with procedures that depend on them could have avoided this tragic event. Later this year, I will undertake a quality improvement project inspired by this patient.

While a physician seeks to recommend a treatment in which the benefits outweigh the risks, those risks are ever-present. Patients are heroes because they take those risks and, more often than not, are simply grateful to be healed. The event that changed this patient’s life activated me to work so that that heroism will never be taken for granted.

| Read Next Essay

Although the case of the paralyzed young man occurred over two decades ago, patient safety continues to be compromised due to poor language access. As a third year medical student, I have personally witnessed several breakdowns in patient safety due to language barriers.

One nearly tragic event occurred during my pediatrics rotation. I was assigned to a community hospital in the suburbs.. A Spanish-speaking two-year old girl was admitted to our service with severe cellulitis. The infection continued to worsen despite initiation of antibiotics in the ER three days prior. Fortunately, the attending physician on service with me was proficient in Spanish and was able to figure out that no interpreter was used when the pain-stricken child first presented in the ER. Consequently, the child’s mom misunderstood the ER physician’s directions and was giving the little girl an inadequate dose of antibiotics.

Once we carefully counseled the mother in Spanish, she was able to administer the correct antibiotic dose and the child’s skin infection and pain improved substantially over the next few days. Had the little girl not been lucky enough to come across my Spanish-speaking attending, she may have gone undertreated and had severe complications.

The near-miss with the cellulitis frightened me into taking medical Spanish classes. But I quickly discovered that even clinicians with language training often overestimate their linguistic abilities, especially as they pertain to cultural competence.[2] Consequently, I instead focused on becoming fluent in navigating interpreter services.

At the onset of any rotation at a new hospital or clinic, I immediately familiarized myself with the interpreter options available at that venue. On several occasions, I was the only member of the medical team that knew the phone number to access remote interpreter services for limited English proficient (LEP) patients. While I may not have saved anyone from becoming quadriplegic, I probably did make a few patients’ lives easier by providing a clear line of communication through a translator. And even when I felt comfortable speaking with patients in a non-English language, such as my first language, Russian, I still used an interpreter as back up in order to prevent missing any critical pieces of information.

The diverse patient populations at my teaching hospitals helped me become proficient in working with LEP patients. These patients also taught me that poor patient safety due to inadequate language access was just the tip of the iceberg when it comes to the negative repercussions of health disparities. To gain a more in-depth understanding of the antecedents of poor health in disenfranchised populations, I took a year off after 3rd year of medical school to move to the West coast and develop a web-based tool to evaluate and improve health disparities (http://bit.ly/eMohMD). The San Francisco Community Vital Signs tool laid the groundwork for neighborhood and hospital-level data that will hopefully inform efforts to improve patient safety and overall care for underserved populations.

Having worked on disparities in patient safety and language access at the city level, I wanted to learn about what was being done on the national level. Through various personal and professional connections, I secured a volunteer internship to write ten speeches on health disparities for a national leader in health policy, U.S. Senator Benjamin Cardin from Maryland.

Motivated by the little girl with cellulitis and by several other instances of compromised patient safety due to language barriers, I was approved to dedicate an entire speech to health disparities among LEP patients. In the speech, I reference several studies that demonstrate how LEP patients are predisposed to receive incorrect or unnecessary medications and to suffer from more severe and more frequent medical complications compared to English-speaking patients.[3] I also site a study in which 32 of 35 language access-related malpractice cases involved failure to use a professional interpreter.[4] The cases resulted in many patients suffering death and irreparable harm including one patient who was rendered comatose, one who underwent a leg amputation, and a child who suffered major organ damage.

Senator Cardin is scheduled to deliver the language access speech in the Spring of 2011 as the fourth speech in his series of ten. The first health disparity speech that I wrote has already been delivered and can be seen here (http://www.c-spanvideo.org/program/id/237988 ) at time mark 1:45:15.

My work at the city and national levels has given me a broader perspective on the implications of compromised patient safety due to language barriers. Recognizing the language access gap in my home state of Maryland, I decided to take advantage of my experience on the hill to improve health for LEP patients where I grew up. Leveraging the relationship with the Senator, I have partnered with a grass-roots coalition of students to advocate for a specific aspect of reducing the language barrier in Maryland health care. In particular, we are trying to convince the Governor of Maryland to take advantage of a federal funding match program whereby the state and the federal government share the fiscal burden of reimbursing interpreters through Medicaid and SCHIP. That’s basically a 50% discount on the cost of saving lives! Twelve states in the country have already leveraged this valuable policy instrument including the nearby state of Virginia and Washington, DC.[5]

The $5,000 from The Doctors Company Foundation and the Lucian Leape Institute would be instrumental in funding the remainder of our effort to educate policy makers about this fantastic match program. In particular, the money would be used for printing brochures, developing a professional video for dissemination via YouTube, and viral marketing via other social media such as Facebook, LinkedIn, and Twitter. I really appreciate your consideration. Thank you, gracias, and spacibo.

References

1. Harsham P. Intoxicado: a misinterpreted word worth $71 million. (malpractice case due to language barrier). Med Econ. 1984;61:p289(3). http://find.galegroup.com/gtx/infomark.do?&contentSet=IAC-Documents&type=retrieve&tabID=T002&prodId=AONE&docId=A3305584&source=gale&srcprod=AONE&userGroupName=mlin_b_bumml&version=1.0.
2. Diamond LC, Reuland DS. Describing Physician Language Fluency. JAMA: The Journal of the American Medical Association. 2009;301(4):426-428. http://jama.ama-assn.org/content/301/4/426.short.
3. Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. 2003.
4. Quan K. The High Cost of Language Barriers in Medical Malpractice. 2010.
5. Chen A, Youdelman M, Brooks J. The Legal Framework for Language Access in Healthcare Settings: Title VI and Beyond. Journal of General Internal Medicine. 2007;22(0):362-367; 367. http://dx.doi.org/10.1007/s11606-007-0366-2.10.1007/s11606-007-0366-2.

| Read Next Essay

• Doug Bonacum, MBA, BS, Vice President of Safety Management, Kaiser Permanente
• Download Slides

Human Factors Engineering

• Linda Williams, RN, MSI, Program Specialist and Cybrarian, VA National Center for Patient Safety
• Download Slides

Just Culture – Part 1

• Suzanne Graham, RN, PhD, Executive Director of Patient Safety, CA Regions, Kaiser Permanente
• Download Slides

Just Culture – Part 2

• Suzanne Graham, RN, PhD, Executive Director of Patient Safety, CA Regions, Kaiser Permanente
• Download Slides

Health Literacy

• Suzanne Graham, RN, PhD, Executive Director of Patient Safety, CA Regions, Kaiser Permanente
• Download Slides

Case Study

• Doug Bonacum, MBA, BS, Vice President of Safety Management, Kaiser Permanente
• Download Slides

Establishing and Managing an Effective Patient Safety Program

• Jason Adelman, MD, MS, Patient Safety Officer, Associate Director, Attending Service, Montefiore Medical Center, Assistant Professor of Medicine, Albert Einstein College of Medicine
• Download Slides