Evaluating Hospital Safety:
A New Rating Tool
The hospital has become the centerpiece of every community. It is a place where life begins and ends. It is a local center where all kinds of people turn up-billionaires, beggars, and everyone in between. They go there to receive comfort and seek a cure for their ills. Some get at least a portion of what they came for, but for many unfortunate others, that is not the case.
Every service area of the medical center has inherent perils that will produce a certain number of fatal or debilitating injuries that are specific to that part of the building and/or those types of services. This is so because there is a fault inherent in the design of our healthcare systems. To comprehend the nature of this flaw, it is vital to examine the various peculiarities of the emergency room, medical or surgical floor, intensive care unit, mother-baby units, operating suite, and postanesthesia care unit (recovery room).
This concept is comparable to a product that is destined to cause damage because its intended function results in an undesired spinoff. For instance, there was a child's doll that was selling off the charts about six years ago because it had a motor mouth that simulated eating. I thought it was great. What a novel idea-we had dolls that could walk, talk, drink, and urinate. Now one could eat and chew solid plastic "food." I bought one for my youngest daughter, Isa, for her fourth birthday. She shrieked with delight when she opened the box. A few hours after she started playing with this thing, I heard her screaming. The doll morphed into a monster that had swallowed a big wad of Isa's hair and kept on chewing its way toward her scalp. We started with a toy that we thought would thrill any child for hours at a time, and we ended with a harrowing menace. Within a few weeks of our incident, Isa's doll was on the six o'clock news and the manufacturer was recalling the product. Apparently, thousands of other little girls had a similar experience. This proved that our incident was the consequence of the toy's design. The engineers' intentions were delight and happiness, and the result was pain and alarm.
Similarly, in the health-care industry, the mission is to ease suffering and save lives, but in hundreds of thousands of patients every year, we get the opposite result because of inherent design defects. This is not just random human error. If it were, we would not see the same mistakes being repeated by different people in every hospital in the country and possibly on this planet.
The commonality of consumer experience causes us to find fault with the mechanical engineering design of the hair-eating doll. Thus using the same logic, we can deduce that if people suffer the same type of injury in a particular area of a hospital in virtually every facility across the country, there must be a series of flaws in what the industry considers a time-honored standard structural design and/or accepted methodologies of delivering the services. We have already seen many generally accepted medical standards change in the face of discovering that a particular style of medical practice or a drug was actually causing harm on a large scale.
One such example was the practice of performing indiscriminate tonsillectomies on children. During the 1940s and 1950s, this procedure was almost as common as haircuts. Now we realize that the tonsils perform a vital function in our resistance to lower respiratory tract infections, so doctors are not inclined to remove these organs unless they are large enough to likely cause airway obstruction.
Another illustration of a seemingly noble intention with a bad result was the Phen-Phen and Redux craze that started as a miracle cure for obesity and ended up causing heart valve damage in thousands of consumers. Plaintiff attorneys accused the involved pharmaceutical executives of rushing to market without adequate investigation for potential side effects.
Lastly, there was the diethylstilbestrol tragedy. This drug actually stopped miscarriages and allowed pregnant mothers to carry their babies to full term. The same substance caused many of the female babies to contract a deadly uterine cancer in their early twenties-another case of noble intent turning into an unimaginable nightmare.