My Father-in-law died due to the negligent use of an off-label medication that was contraindicated for his medical conditions. Despite the attending doctor and nurse being warned by the pharmacist of a possible life threatening reaction, the doctor told us that there were no risks. Unfortunately the pharmacist’s warning was not communicated to my Father-in-law, to us, or documented in the medical records. This tragic experience transformed my wife and me into patient safety advocates.
After my Father-in-law’s death, we found out multiple issues with the doctor who gave the fatal drug; despite him telling us that he was a pulmonologist, he was in fact not board certified and had failed his pulmonary board exam twice. When asked why he did not tell us the pharmacist’s warning, he claimed that as a doctor he knew better than patients or the pharmacist and therefore he did not need to inform patients about drug warnings, only he had the knowledge and training to make these medical decisions for patients.
Based on our belief that this was a serious violation of our patient rights, we filed a complaint with the state medical board. After 6 months, they sent us a very brief letter stating that the doctor’s care met the standard without providing any explanation. When I called the then Director of the medical board asking for an explanation, she told me that “The law does not require me to tell you anything, so I will not.” We sought legal advice only to find out that our state medical board has complete autonomy.
So, we talked to our state legislators to try to change the laws. We worked with them and co-authored a bill to improve the transparency of the medical regulatory agencies in Washington State. This new law requires the state regulatory boards to provide people who file complaints over concerns of quality of care with an explanation of the boards’ decisions and to guarantee people the right to file for case reconsideration when the case is closed without an action. On the day when our bill was signed into law, we celebrated a victory to protect patient rights.
To ensure that the hospital was providing quality of care, the Centers for Medicare and Medicaid Services (CMS) reviewed my Father-in-law’s records. Based on that, they cited the facility for one violation of patient rights and additionally four violations of standard care.
As a result of all the above events, I have become painfully aware of the staggering magnitude of the health care problem in our country and that there are many other people besides my Father-in-law and family that have been needlessly affected or killed by preventable medical errors. In fact, medical error is now the third leading cause of death in America. We need to find a way to change our broken medical system. To do this, we need to get many more people involved, so that we have enough people power to demand the changes and to stop these unnecessary deaths.
To achieve this goal, my wife and I formed Washington Advocates for Patient Safety, a grass roots non-profit. We and our members work to educate the public, legislators, and medical professionals on patient safety issues and how to improve the system. Members of our organization are now serving on a number of federal and state agencies, such as the Washington State Health Acquired Infection Advisory Committee, Washington State Medical Board, Communications Resolution Program (CRP), FDA drug advisory committee representative, National Quality Forum, and many more.
In recognition of our work and dedication, my wife and I have been asked to teach as faculty members at the University of Washington, School of Medicine for the national AHRQ TeamSTEPPS training and for the Train the Trainer Projects. Both trainings aim to improve inter-professional communications among medical professionals. Working together, we are making a difference.