Tuesday, March 9, 2010

Doctor Leads Quest for Safer Ways to Care for Patients - NYTimes.com

A. My father died at age 50 of cancer. He had lymphoma. But he was diagnosed with leukemia. When I was a first-year medical student here at Johns Hopkins, I took him to one of our experts for a second opinion. The specialist said, "If you would have come earlier, you would have been eligible for a bone marrow transplant, but the cancer is too advanced now." The word "error" was never spoken. But it was crystal clear. I was devastated. I was angry at the clinicians and myself. I kept thinking, "Medicine has to do better than this."

A few years later, when I was a physician and after I'd done an additional Ph.D. on hospital safety, I met Sorrel King, whose 18-month-old daughter, Josie, had died at Hopkins from infection and dehydration after a catheter insertion.

The mother and the nurses had recognized that the little girl was in trouble. But some of the doctors charged with her care wouldn't listen. So you had a child die of dehydration, a third world disease, at one of the best hospitals in the world. Many people here were quite anguished about it. And the soul-searching that followed made it possible for me to do new safety research and push for changes

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Dr. Peter J. Pronovost, 45, is medical director of the Quality and Safety Research Group at Johns Hopkins Hospital in Baltimore, which means he leads that institution's quest for safer ways to care for its patients. He also travels the country, advising hospitals on innovative safety measures. The Hudson Street Press has just released his book, "Safe Patients, Smart Hospitals: How One Doctor's Checklist Can Help Us Change Health Care from the Inside Out," written with Eric Vohr.