Stop Medical Errors NOW!

Important:

Black List
Physicians and Hospitals

Tell & Repair
Legal Proposal






For international developments
concerning medical
errors and patient
safety see:
www.ieu-alliance.eu

Please report
medical errors to:
info@sin-nl.org


Reports on patient safety

 Eight Futures Forum
WHO 2005 Governance of Patient Safety (3.35mb)

When things go wrong, responding to adverse events
Harvard rapport 2006

News

News
 Report Conference Victims of Medical Errors, April 23 2008.
 Conference on April 23rd 2008: Our Motto: Help victims of medical errors!
 February-March 2008: progress Tell and Repair Provision
 Letter to Minister A.Klink conc. Tell and Repair legal provision, 16th of January 2008
 The 'other' blacklist. 7 years no care in spite of disability by medical error, 7th Jan. 2008.
 Inspectorate of Health Care signs legal proposal Tell and Repair, 19th Dec.2007.
 Week of Patient Safety 22-29 November 2007. Inspectorate Healthcare refuses to inspect.
 Common meeting to improve aftercare, 7th November 2007.
 Medical errors and the Association of Medical Consultants. Breakthrough 17th Oct.2007
 Aftercare to victims of medical errors is practically nil: Questions 16th sept. 2007.
 Let doctors pay for their medical errors, and not the patients, sept. 2007.
 Breaking News: finally acknowledgement no aftercare for victims, 6th September 2007
 SIN-NL and IEU-Alliance in the media.
 Newsitems March 2006 till July 2007
 Summer Actionplan:measures to reduce medical errors, 24th of July 2007
 Call to physicians,nurses and hospitals, 8 July 2007
 Reaction on plan on patient safety, June 12th 2007.
 Nivel/Emgo Report (25th April 2007) raises more questions, May 2007.
 General amnesty: for victims and causers of medical errors?Ab Klink heads in the correct direction.
 How do I survive healthcare? Alice Fuldauer, april 2007
 Medical errors and medical records, proposal for change, March 2007
 Agreement Blame-free Incident Reporting 1 February 2007: why blame-free? Part 1.
 Agreement Blame-free Incident Reporting 1 February 2007: why blame-free? Part 2.
 2007: YEAR OF AND FOR VICTIMS OF MEDICAL ERRORS, jan. 2007
 Conferences patient safety and reporting medical errors, nov.2006
 Selfregulation fails, insurance and accreditation institute owned by medical field, sept.2006
 Physicians prefer non-disclosure, study reveals, august 2006
 Prevention of medical errors and money, june 2006
 Doors to dialogue are open, june 2006
 Toplawyer medical association aknowledges denial and cover-up of medical errors by physicians, may 2006
 Presentation of the Declaration of the IEU-Alliance to Mr Hoogervorst, Minister of Healthcare, april 2006
 Major breaktrough: Harvard hospitals adopt goals of SIN-NL and IEU-Alliance, march 2006
 Survey of medical errors: epidemiology, march 2006
 The Medical Disciplinary Tribunal and medical errors: symposium, february 2006
 Letter to the Dutch Prime Minister, january 2006
 Opinion-poll on medical errors, november 2005
 
Report Conference Victims of Medical Errors, April 23 2008.
Report Conference Victims of Medical Errors, April 23 2008 Utrecht Netherlands.

April 23rd 2008 the medical field organised the first national conference for victims of medical errors. The Dutch Association of Hospitals, (NVZ) representing 100 hospitals, the Association of Medical Consultants, (OvMS) representing 16.000 physicians and the Association of Nurses and Caregivers (VenVN), representing 200.000 nurses and caregivers were present as well as consumers, patients and victims organisations.
The conference was organised as a result of strong pressure by SIN-NL and the IEU-Alliance. This was acknowledged by all present.

These are the results of the conference:
The Chair of the meeting Ms Marian Kaljouw Ph.D. Chair of the Nurses expressed her deep shame about the fact that the medical field so far does not or almost does not give care to victims of medical errors. The NVZ and the OvMS did not contradict this statement and were silent.
We compliment Marian Kaljouw with her honest and courageous statement.
The entire meeting was and acknowledgment of the horrible situation of victims of medical errors and their relatives.
The consumers, patients and victims organisations proposed the following:
-the immediate release of honest information
-the immediate arrangment of adequate remedial medical care to limit the damage.
Both represent the essence of the legal provision Tell and Repair of SIN-NL/IEU-Alliance.
-the immediate release of the medical records to the victims and their relatives
-SIN-NL/IEU-Alliance proposed to give a copy immediately after each consultation to the patient in order to enable them to approve the contents. Thus incomplete or incorrect records can be prevented, as mentioned in the NIVEL report of 2007.
-to oblige physicians, nurses and hospitals to learn from their errors.
-the Council of the Disabled and Chronically Ill made a remarkable proposal to install instantaniously a high fine on the refusal of honest information and remedial medical care. They also pleaded for a more active and efficient attitude of the Inspectorate of Healthcare. We certainly do agree with both proposals.
-the Consumersfederation pleaded for more transparency and publishing of medical errors, including those who are sent to the Inspectorate of Healthcare. We support this.
It was acknowledged that medical assistance to the present victims of medical errors has to be organised short term and that one should not wait for guidelines or laws.
We do regret that the medical field so far refrained from formulating their reaction to our legal provision Tell and Repair which has been signed by the Inspectorate of Healthcare and which has been approved by the lawyer J.Legemaate of the Dutch Association of Physicians and will be dealt with by the Ministry of Healthcare in the preparation of the new law Client and Quality of Care.
We emphasized that the rendering of honest information and remedial medical care is part of the regular and legal obligations of physicians and nurses. Therefor the use of the word aftercare was abandoned.
Within four weeks another meeting will be organised to develop a practical plan to improve the situation of the present and future victims of medical errors and their relatives. SIN-NL and the IEU-alliance were represented by Peter van den Berk and Sophie Hankes, and two members of staff.


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Conference on April 23rd 2008: Our Motto: Help victims of medical errors!
Following our common meeting on November 7th 2007 with the Dutch Association of Hospitals , the Association of Medical Constultants and the Association of Nurses and Caregivers concerning the introduction of our legal provisionTell & Repair these three organizations have decided to organize an invitational conference on April 23rd 2008.
The aim is to be informed about the wishes of patient-victims regarding care after a medical error. Apart from SIN-NL/IEU-Alliance, the writers of Tell & Repair, four organizations are invited to present their vision. Nothing else on the conference's agenda is known.
In this matter, we want to make the following remarks.
- The date, April 23rd 2008, has never been discussed with us.
- It is not about the patient's "wishes". It is about illness and suffering. It is out rights. It is about legal obligations of the medical sector which are clear for years.
- In this way the three organizations we named above have not met their obligations of November 7th 2007. They were obliged to give their reply on our legal preveisions before March 15th 2007.
They, the representatives of the medical sector, have legal obligations toward the victims of medical errors.
-It has been known that some of other consumers and/or patientorganizations either work closely with the medical sector (may we call this collaboration?) or have refused to actually help victims of medical errors. What are their hidden agendas? How useful is their contribution?
- Of course it is a postive that this conference will be organized but... it has been known for years what victims of medical errors and their relatives want:
1. Honesty and openness
2. Adequate follow-up diagnostics en adequate remedial medical care.
3. Registration, research and prevention of medical errors.
There is no difference of opinion in these matters.
- It does not concerns the lack of "aftercare": it is all about the regular obligations of physicians and nurses, who are obliged to be honest and give adequate medical care.
- Medical sector:
Have you ever heard of your duty to supply care?
Have you ever heard of continuity of care?
Have you ever heard of the access to care?
Or do you consider these questions too assertive and critical?
- The medical sector has clear obligations toward patients and victims of medical errors. For more information, see the WGBO, the inaugural speech Legemaate in 2006 lawyer of the Dutch Medical Association and the clear opinion of Professor Sijmons, Healthlaw at University of Utrecht on Januari 14th 2008.
- The medical sector has the legal obligation to report medical errors, art 4a of the Law on Quality.
- Also, Legemaate of the KNMG states on page 148 of his book Safe Incident Reporting that the Havard Consensus report, on which we fully based our Tell & Repair proposal, is directly applicable in the Netherlands without too much adaptations.
- So, what is the medical sector waiting for? Or are they really incapable to read or listen? Why this conference? Is it about image? Is it about giving the media and the population the impression that they really are trying to help victims of medical errors?
- No more words, it is time to take action, medical sector! Only then you will be credible. As of today you can start being honest to victims of medical errors and their relatives and give us adequate diagnostics and remedial medical care. Up until now you are refusing this, as you acknowledged on November 7th 2007.
- We will be present on April 23rd 2008 to advocate our case, and will continue to attempt to bring about a change of heart in the medical sector.
- Moreover, in our opinion, refusing honest information and medical care to victims of medical has to be incorporated into criminal law. It is the same thing as to the hit and run phenomenon after a traffic accident:to drive onwithout arranging medical help, which is also illegal.
- We have formulated another legal provision and will offer this to the people whom this concerns. This legal provision is based on the assumption that serious negligence should be incorporated in criminal law. This assumption was made by Harry van Hulsteijn, vice-president of the Association of Medical Specialists on November 7th 2007. All present agreed, including the representatives of the Assiociation of Hospitals and the Association of Nurses.

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February-March 2008: progress Tell and Repair Provision
  • On the 13th of February 2008 the Dutch Ministry of Healthcare wrote:
    - that they attach much value to honest information and remedial medical care to victims of medical errors
    - that they would imply the Tell and Repair provision in their considerations in the preparation of the new law Client and Quality of Care, letter available.


  • On the 10th of March 2008 the Dutch Association of Hospitals, the Association of Medical Consultants and the Association of Nurses and Caregivers Netherlands wrote:
    - that they will organise a conference on the 23rd of April 2008 to list the wishes of victims of medical errors and
    - that the Tell and Repair provision will be formulated as an official NTA protocol at the end of 2008.


    • Certainly it is important that the need for improvement of honest information and respectful adequate treatment of victims of medical errors is acknowledged and subject of serious discussion. However we emphasize that sofar no actual progress has been realized. So far the improvement of the position of victims is only a matter of words and not action. It should be clear that many victims are in desperate need of actual medical assistance.
    We stress the urgency of the situation and appeal to all active in healthcare to speed up the process to achieve true patient safety, not only for the future, but also and especially for the present.

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    Letter to Minister A.Klink conc. Tell and Repair legal provision, 16th of January 2008
    Letter to Minister Klink concerning Tell and Repair legal provision,
    16th Januari 2008

    On the 16th of January 2008 we had a short personal meeting with the Dutch Minister of Healthcare Ab Klink. Afterwards we handed this letter to him.

    Ministry of Healthcare
    Attention of Minister Dr. A. Klink
    Postbus 20350
    2500 EJ Den Haag 16 januari 2008

    Concerning: situation and implementation of Tell and Repair Legal Provision

    Your Excellence,

    Our last letter to you was written on the 31th of July 2007. Unfortunately we have had no personal meeting with you nor your top civil servants who are responsible for the quality of care and patient safety.
    It is known and acknowledged that the situation of medical errors is very serious, in quantity and in consequences.
    The last months several important developments occurred.
    On the 7th of November 2007 the Dutch Association of Hospitals, the Association of Medical Consultants and the Dutch Association of Nurses and Caregivers acknowledged again that physicians give almost no aftercare, honest information and adequate remedial medical care, to victims of medical errors.
    On the 6th of September 2007 the Inspectorate of Healthcare acknowledged that they were aware of the lack of aftercare to victims of medical errors.
    On the 7th of November 2007 the three professional organisations took it upon themselves to formulate a proposal to improve the aftercare to the present and future victims of medical errors, based on the SIN-NL/IEU-Alliance legal proposal Tell and Repair, based on the van Harvard Consensus Rapport (2006) When Things go wrong: Responding to Adverse Events.
    On the 19th of December 2007 the Inspectorate of Healthcare signed the legal proposal Tell and Repair and thus supports this important initiative. The Inspectorate also indicated that it was urgent to organise a meeting between the Ministry for Healthcare and the undersigned.
    We therefore request to you to arrange a meeting about the implementation of the Tell and Repair legal proposal. Subject of this meeting will be whether the legal proposal should be incorporated in the present Law on Medical Treatment, or should be incorporated in the new Law Client and Quality of Care.
    Certainly we will appreciate a personal meeting with you. When this is not possible, we will appreciate to receive your personal answer.
    We repeat:our motive is to prevent or to diminish preventable sorrow to innocent fellow-human beings. We trust that you will support this goal.
    Awaiting your reply at your earliest convenience, yours

    Sophie Hankes LL.M.
    Chair SIN-NL www.sin-nl.org
    Chair IEU-Alliiance www.ieu-alliance.eu
    Enclosed: legal proposal Tell and Repair



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    The 'other' blacklist. 7 years no care in spite of disability by medical error, 7th Jan. 2008.
    Herewith we ask your attention for the following:
    Please be aware of another black list, next to the black list of physicians published by SIN-NL December 6 th 2007.
    The ‘other’ black list is composed by and for physicians. It contains the names of victims of medical errors and members of their families. Physicians are afraid that victims are only focussed on money and will immediately start legal procedures, they view patients as potential litigants. Therefore physicians will not give honest information nor follow-up diagnostics, nor genuine remedial medical assistance care.
    The refusal to acknowledge the medical error will thus prevent succesful litigation.
    This attitude is known as the cover-up ,the closing of the ranks or the wall of silence, see article in Elsevier December 1st 2007 by Willem Wansink.

    Various organisations have confirmed this practise a.o. the Health Inspectorate on the 6th of September 2007 and on the 7th of November 2007 the Association of Medical Consultants, the Association of Hospitals and the Association of Nurses and Caregivers in the Netherlands
    This blacklisting is unacceptable , because it means that patients who are chronically and or progressively ill caused by medical errors, will probably NEVER obtain good medical care.
    We know of persons who have been without honest medical care for seven years and more.
    Image yourself in their position. These patients have to live with this refusal day by day and so far they are powerless and helpless.
    Moreover one can ask:
    -who decides about blacklisting?
    -what are the criteria?
    -is their an end-date, or is it infinitive?
    -how do you make the blacklisting undone?
    -who can you approach about the blacklisting?
    It is truly a frightening Kafka-esk situation.

    It is however remarkable that the patients and members of their families are blacklisted and put in this extremely difficult situation, whilst actually those who are responsible for the medical errors and the consequences, the physicians should be corrected and sanctioned.

    How would physicians feel to be blacklisted? As soon as SIN-NL published the blacklist of the physicians we were confronted by lawyers and received a letter of the association of hospitals representing physicians, and nurses to announce a boycott of SIN-NL.
    However we also made the national headlines and were interviewed ao on the radio.

    Who can change this situation?
    This the task of the media, the authorities and the responsible professional groups, the medical associations, the organisations of patient safety and quality of healthcare.
    As soon as victims of medical errors are removed from the blacklist and receive genuine information as well as genuine remedial medical care, we will remove the blacklist of physicians.
    Also it is necessary that all medical professionals register their medical errors, according to their legal obligations, examine their medical errors and develop and realize prevention.
    Honesty is more important than the professional allegiance!

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    Inspectorate of Health Care signs legal proposal Tell and Repair, 19th Dec.2007.
    Again we made important progress.
    On the 19th of December2007 Nico Oudendijk, Deputy Inspector-General of the Inspectorate of Healthcare has signed the legal proposal “Tell and Repair”. He also expressed his understanding for publication of the Black List.
    Mr. Oudendijk also agreed to have regular meetings with SIN-NL/IEU-Alliance, once in 3 months, in order to discuss the situation of patient safety and the position of victims of medical errors on a regular basis.
    He also agreed to discuss a protocol on medical errors and to involve us in an internal investigation on the way employees of their service deal with complaints by patients and victims of medical errors.
    We hope that the regular meetings with the Inspectorate of Health Care will lead to substantial improvements of the position of victims of medical errors and patient safety in general.


    Sophie Hankes and Nico Oudendijk signing the “Tell and Repair”legal proposal, 19 Dec.2007

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    Week of Patient Safety 22-29 November 2007. Inspectorate Healthcare refuses to inspect.
    The Inspectorate of Healthcare does not inspect properly as she refuses to examine the so-called “individual cases.
    We are talking about appr. 20 persons who die each day and about 20 persons who become disabled each day, due to medical errors in hospitals in the Netherlands.
    In ten years this concerns appr. 16.000 people!
    Thus the problem of victims of medical errors is structural.
    Moreover: physicians refuse to give victims honest information and refuse to give victims adequate medical care.
    This had been acknowledged on the 7th of November 2007 by the Association of Medical Consultants, the Association of Hospitals and the Association of Nurses and Caregivers in the Netherlands
    This is the same as the “hit and run” phenomenon: to leave a victim of a road accident without care. This is a crime.
    However in case of the medical error, the responsible physician simply continues his job and can continue to dysfunction
    This shows enormous disrespect for the victim and for the Dutch population.
    On top of that the Inspectorate of Health Care does not comply to her official legal obligations. Do you accept that the police refuses to search for the person who left the victim of a road accident unattended? Again, leaving a victim without assistance is a crime according to art. 7 of the Law of Traffic in the Netherlands.
    The Inspectorate of Health Care informed us they focus on the future and focus on prevention of medical errors.
    No lessons are learned from medical errors and the victims are left without medical assistance. We will approach the authorities to improve the situation on short term.

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    Common meeting to improve aftercare, 7th November 2007.
    Finally! After two years of hard work, we succeeded in organising a common meeting with the Association of Medical Consultants, the Association of Hospitals and the Association of Nurses and Caregivers, Dimitri.nu and SIN-NL/IEU-Alliance.
    Appr. two hours before the meeting would begin, the Association of Medical Consultants and Hospitals threatened to call it off. The did not want to allow the ANP, the main Dutch Press Office to be present.
    Unfortunately we could not convince them that openness and transparency is the best policy.
    So the meeting took place.
    All present agreed that:
    -the reporting of errors to chiefs of department, the directorate and the executive board should be obviously done
    -it should be natural to inform and give adequate remedial medical care to victims of medical errors in accordance with the Law on Medical Treatment Agreement (WGBO), the Oath of Hippocrates, next to the professional and ethical duties of physicians and nurses.
    Dimitri.nu and SIN-NL/IEU-Alliance made it clear that the NPCF nor the Consumers-association protect the interests of victims of medical errors and that patient safety is not a priority of the NPCF.
    We stressed the importance to introduce and implement measures such as the Tell and Repair proposal, as soon as possible. Reluctantly we agreed to accept a delay of 4 months.
    The associations took it upon themselves to formulate a plan to improve the aftercare-honest information and adequate remedial medical care- for victims of medical errors, before the 15th of March 2008. It would be based upon the Tell and Repair proposal of SIN-NL/IEU-Alliance and incorporated in the plan to reduce medical errors, June 12th 2007.
    We emphasized that the obligation for honest information and remedial medical care already exists on the basis of the Law of Medical Treatment Agreement. The professional organisations said that were limited by the mentality of their colleagues and demanded the 4 months of preparation. We offered to send additional information.
    Harry van Hulsteijn of the Association of Medical Consultants suggested to refer victims to their former physicians, who caused the medical error. We cannot accept this suggestion.
    Experience has taught us that it is almost impossible to expect from a physician who has refused for year to give honest information and adequate remedial medical care and had imposed the wall of silence to the victim, to suddenly change his ways and be open and honest.
    We made it clear we would not accept radio silence until the 15th of March 2008.
    Communication is the basis of respect for partners who decided to prepare a proposal.
    It was concluded that the parties would communicate via telephone and letters.
    Thus the 7th of November 2007 constitutes an important milestone:
    As far as we know, it is the first time that in the Netherlands, Europe and worldwide,
    professional medical organisations held a common meeting with organisations of victims of medical errors. It is the first time that the professional organisations obliged themselves to formulate a plan to improve the aftercare to victims of medical errors. Dr Harry van Hulsteijn repeated his offer to help urgent victims of medical errors.

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    Medical errors and the Association of Medical Consultants. Breakthrough 17th Oct.2007
    On the 17th of Ocotber 2007 we had our first meeting with the Association of Medical Consultants. Finally after two years of sending letters and emails.
    We met with dr Harry van Hulsteijn, deputy chair and chair of the commission Science, Education and Quality and with Ms dr Hedwig Slot, neonatologist and secretary of the commission SEQ.
    John Kleijn of Dimitri.nu was also present on our invitation.
    Seldom we had such a positive meeting. We discussed the position of victims of medical errors
    Dr van Hulsteijn repeated his public acknowledgment of September 3rd in Nijmegen that the aftercare to victims of medical errors is practically nil Er is no misunderstanding: this means that physicians give victims of medical errors hardly to none honest information nor adequate follow-up diagnostics nor adequate remedial medical care. Dr van Hulsteijn said that physicians were very worried by their fear of damage to their reputation. He would have been completely honest if he had added that physicians fear litigation, which was already acknowledged by J.Legemaate, lawyer of the Association of Physicians (KNMG) in his inaugural speech, may 2006.
    Van Hulsteijn said that quality should have priority over money.
    He thinks the hospital has the responsibility to improve the aftercare in a structural way.
    The physician however has an integrated responsibility within the framework of the hospital. It is necessary to make national rules and agreements.
    We offered him the legal proposal “Tell and Repair”, based on the Harvard consensus report from 2006. The basis is honesty and openness and completely in line with the new opinion of the Assocation of Medical Consultants.
    This means a change of change of direction.
    It is necessary however to prevent medical errors as much as possible, to work as professional as possible as a physician and a nurse and also offer adequate aftercare.
    Van Hulsteijn stressed that the Tell and Repair procedure should be build in the framework of blame-free reporting.
    He offered to refer present victims of medical errors to medical consultants in cooperation with the scientific medical assocations, after consultation with SIN-NL/IEU-Alliance.
    The legal proposal Tell and Repair will be the basis of the development of aftercare for victims/families of medical errors. Van Hulsteijn agreed to involve SIN-NL/IEU-Alliance and Dimitri.nu in each meeting on aftercare and each meeting on victims of medical errors.
    He requested to formalize the plans on aftercare in our meeting with the Association of Hospitals end of October 2007 and in the common meeting of the 7th of November, with the 3 professional organisations. It might be possible to sign a agreement then.
    This meeting of the 17th of October 2007 means a breakthrough for the improvement of the position of victims of medical errors. Words should be realised in action. We shall keep you informed.

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    Aftercare to victims of medical errors is practically nil: Questions 16th sept. 2007.
    On the 3rd of September 2007 dr Harry van Hulsteijn, deputy Chair of the Assocation of Medical Consultants and Chair of the Commission Science, Education and Quality acknowledged in a public debate in Nijmegen, Netherlands that the aftercare to victims of medical errors is practically nil.
    On the 6th of September 2007 Nico Oudendijk, deputy Inspector-General of the Inspectorate of Healthcare acknowledged that they were aware of this refusal of medical assistance to victims of medical errors.
    We asked both gentlemen: what will you do to improve the situation, but silence followed….
    We have more questions:
    -what is your definition of aftercare?
    -do you agree that aftercare means: honest information and remedial medical care?
    -why do physicians refuse to give victims of medical errors aftercare?
    -why do physicians refuse to inform familily members of deceased victims of medical errors honestly that there was a medical error?
    -are physicians afraid to inform victims that they made an error, as acknowledged by Johan Legemaate lawyer of the Royal Dutch Medical Association, in his inaugural speech may 2006, for fear of litigation?
    -since when do physicians refuse to give aftercare to victims of medical errors?
    -is it ethically acceptable that physicians do not give aftercare to victims of medical errors and abandon them?
    -is it reasonable of the Royal Dutch Medical Association to ask that physicians are not responsible for medical errors and do not get punishment?
    -isn’t it time that physicians stop the wall of silence to and abandonment of victims of medical errors and start to give the victims honest information and remedial medical care?
    -how do you want to arrange good aftercare for the present victims of medical errors?
    We request physicians and the Inspectorate of Health Care:
    Wij vragen aan de artsen en aan de Inspectie Gezondheidszorg:
    IS IT VERY INCONVENIENT TO ARRANGE CORRECT AFTERCARE TO THE PRESENT VICTIMS OF MEDICAL ERRORS AND TO ARRANGE HONEST INFORMATION TO THE MANY SURVIVING RELATIVES, NOW AND IMMEDEATELY?
    Please put yourself in the position of victims and surviving relatives.
    Most of them for years, did not receive honest information nor remedial medical care, in spite of death and or progressive disability.
    You can examine and learn from your errors when you are honest.
    Honesty prevents that you harm innocent victims and their relatives further.
    To the Inspectorate of Healthcare: please take your responsibility and improve the situation!

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    Let doctors pay for their medical errors, and not the patients, sept. 2007.
    Richard Lord and Dr. Marylou Buyse

    We pay for medical errors September 12, 2007 Boston Globe

    WHAT IF your mechanic forgot to replace the lug nuts after changing one of your tires and you got into a serious accident when the wheel came off? You wouldn't expect your mechanic to send you a bill for the repairs, would you?

    Unfortunately, that's what happens in healthcare and we pay a high price for mistakes.

    Eight years have passed since the Institute of Medicine's landmark study, "To Err is Human," which found that as many as 98,000 patients die each year in America's hospitals as a result of medication overdoses, postsurgical infections, and other medical errors. These are preventable deaths, yet medical mistakes cause more deaths than car accidents, breast cancer, or AIDS.

    Even when mistakes are not fatal, they can still have devastating results. They can lead to injury, disability, extended hospital stays, or lengthy recoveries. And we often pay twice when errors occur - once for the mistake and again to correct it. Nationally, the cost of preventable medical errors, lost income, and lost productivity is estimated at $17 billion to $29 billion a year.

    Employers bear a large part of that expense. In Massachusetts, more than four out of every five insured individuals under the age of 65 receive coverage through an employer. So when preventable errors occur, it is businesses that pay.

    Take, for example, routine bypass surgery, which can cost more than $50,000. When a sponge or a surgical instrument is left inside the patient, correcting the mistake can add tens of thousands of dollars to the cost of caring for that individual. These errors should never happen, but are far too frequent and, ultimately, employers are left paying the bill through higher health and disability premiums.

    Medical care in Massachusetts is the most expensive in the country - $7,075 per resident is spent every year, compared with the national average of $5,313. Healthcare costs are increasing three times faster than the annual rate of inflation, and the quality of care can vary between and among healthcare facilities.

    On many measures, Massachusetts healthcare providers and medical institutions are the envy of the world, but we can do more to improve the quality of care in the state. We can start by raising the bar higher, through public reporting of medical errors and by removing the financial benefit when serious mistakes occur.

    Legislation to require public reporting of medical errors that will be heard by the Legislature's Public Health Committee today is a good place to start, and many in the healthcare system have been working to make that information available. Still, we can go farther. The legislation should be revised so that providers are not allowed to bill for the extra costs of treating preventable errors, injuries, and infections that occur in hospitals.

    Healthcare entities should not be rewarded financially when such preventable errors occur. Hospital-acquired infections offer one example. An August 2007 report by the state's Betsy Lehman Center for Patient Safety and Medical Error Reduction found that infections contracted during a hospital stay could be causing up to $473 million in medical costs annually in Massachusetts. Meanwhile, there are hospitals around the nation that have driven their infection rates down to zero.

    Prohibiting billing for so-called "never events" is another example. These are rare but serious medical errors that should never happen to a patient, such as conducting surgery on the wrong body part, leaving a foreign object in a patient after surgery, or patient death or serious injury resulting from a medication error.

    While healthcare facilities currently are required to report major medical incidents to the state, these reports are not readily available or useful to the public. In 2005, the state's Board of Registration in Medicine issued a report that found that healthcare facilities reported 24 never events the prior year, but did not identify the institutions, leaving both patients and the healthcare system unaware where these mistakes occur. We need stronger measures in place to prevent these errors from continuing to happen.

    No other industry generates revenue from mistakes. Preventable errors should not be part of the usual cost of healthcare.

    Richard Lord is president and CEO of Associated Industries of Massachusetts. Dr. Marylou Buyse is a practicing primary care physician and president of the Massachusetts Association of Health Plans.

    © Copyright 2007 Globe Newspaper Company







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    Breaking News: finally acknowledgement no aftercare for victims, 6th September 2007
    Acknowledgment that follow-up care of victims of medical errors is practically nil.
    Institution of “Tell and Repair” legal proposal necessary.

    The Dutch organisation of Medical Consultants openly acknowledged on the 3rd of September 2007 during a public debate organised by the Radboud University Medical Center in Nijmegen, Netherlands, that the follow-up care to victims of medical errors is practically nil.
    This acknowledgment is of major importance.
    In a meeting on the 6th of September 2007 with Chair Sophie Hankes LL.M of SIN-NL/IEU-alliance the deputee Inspector-General of the Dutch Health Inspectorate confirmed that physicians do not give honest and open information nor adequate follow-up medical care to victims of medical errors.
    As the situation was so clear he did not deem it necessary to start investigations.
    Oudendijk admitted that complaint-boards of hospitals do not deal adequately with complaints of victims of medical errors. He pointed out that in addition to the physicians and nurses, the leadership of the hospital is also accountable for medical errors.

    Sophie Hankes requested institution of the “Tell and Repair” legal proposal in order to achieve that victims of medical errors would receive honest information and remedial medical care.
    She also requested that surviving relatives would be informed in an honest and open way.
    Deputee Inspector-General Oudendijk agreed to give his written support for the “Tell and Repair” proposal before the 1st of January 2008.

    Moreover the Dutch organisation of Medial Consultants, the Dutch Association of Hospitals and the organisation of Nurses and Caregivers VenVN, as well as the Center of Nursing Expertise LEVV, have explicitly agreed to attend a common meeting with SIN-NL/ IEU-Alliance to discuss improvement of the position of victims of medical errors.


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    SIN-NL and IEU-Alliance in the media.
    To watch the television broadcasts please click:
    10-01-2008 Hart van Nederland 22.30uur
    07-12-2007 Kassa radio 11.45uur
    06-09-2007 BNR radio
    06-09-2007 RTV Utrecht
    30-07-2007 Hart van Nederland 22.30uur
    12-06-2007 RTL4 nieuws 19.30uur
    10-05-2006 Radio 1 NOS

    To read the articles, please click (downloading of pdf will take several minutes):

    19-05-2008 weblog Maurice de Hond
    28-04-2008 Qure
    25-03-2008 Geestig: Verenigingsmagazine UFSW
    05-03-2008 Limburgs Dagblad
    O5-03-2008 TC Tubantia
    04-03-2008 Metro
    22-02-2008Parool
    05-02-2008 De Stentor
    00-01-2008 School voor Journalistiek, Utrecht
    26-01-2008 Arts en Auto nr 2, 2008 page 4
    10-01-2008 Mednet
    08-01-2008 Zorgvisie
    07-01-2008 Algemeen Dagblad
    04-01-2008 de Limburger
    11-12-2007 Leeuwarder Courant
    06-12-2007 Metro voorpagina
    06-12-2007 Metro pagina 3 (vervolg)
    01-12-2007 Elsevier
    10-09-2007 TROS Radar
    07-09-2007 Radbode pag.16 nieuwsbrief van het UMC Radboud
    03-09-2007 Het Echte Nieuws
    09-06-2007 TC Tubantia
    28-04-2007 NRC Handelsblad
    26-04-2007 Het Parool
    15-03-2007 Elsevier Magazine
    06-12-2006 Intermezzo
    01-12-2006 HPDeTijd
    14-06-2006 Trouw
    27-01-2006 Medisch Contact nr 4
    July 2007 Top Santé magazine
    May 2007 Linda magazine




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    Newsitems March 2006 till July 2007
    SIN-NL introduces Summer- actionplan to reduce medical errors immedeately; TV programm SBS6 "Hart van Nederland" broadcasts interview with Sophie Hankes 30 July 2007 ,
    see news

    call for meeting with physicians, nurses and hospitals, pressrelease 8 July 2007, see news.

    recommendation:please read:
    Gallagher Th, Studdert D., Levinson W.: Disclosing medical errors to patients:current concepts.
    New England Journal of Medicine 28 June 2007 356:26 2713-2719
    Publisher Houghton Mifflin Company www. njem.org
    This review article is written by prominent members of the medical and legal profession.

    Important developments concerning medical errors in the Netherlands 2007.
    Nivel/Emgo report about adverse events in hospitals leads to acknowledgment that too many errors occur: by government, physicians, nurses, politicians : 25 April 2007
    NPCF acknowledges that :good information and remedial medical care necessary for victims, 13 June 20007
    Inspectorate Healthcare acknowledges that :examination of position of victims and improvement is necessary,17 June 2007
    Thus NPCF and Inspectorate for Healthcare acknowledge goals of SIN-NL and IEU-Alliance!

    Reaction on actionplan for patient safety: compliments! Dutch Consumer Patient Federation NPCF adopts goals of SIN-NL!
    See news

    SIN-NL presents Tell and Repair proposal to Minister Ab Klink and is broadcasted on national television, RTL June 12 07.

    General Practioners added to Red List.

    Red list healthcare and Tell & Repair legal provision proposal in view of congress Inspectorate of Healthcare 12 June 2007

    Nivel/Emgo Report on medical errors in hospitals raises more questions, SIN-NL calls for cooperation to improve the position of victims of medical errors and patient safety,
    see Netherlands.

    Nivel/Emgo Report on medical errors in hospitals, based on study of medical records raises several questions as 76% of the medical records was inadequate, and Chief Inspector of the Inspectorate of Healthcare acknowledges that the number of errors is incorrect and should at least be doubled, see News

    General amnesty for victims and perpetrators of medical errors? Minister Klink heads in the right direction, what will the physicians do?, see News

    Dutch press publishes interview and quotes from SIN-NL nationwide, April 2007.

    summary of comments of SIN-NL on Nivel/Emgo report on medical errors in Dutch hospitals, to be published soon on this website

    April 2007:New book on medical errors and patient safety in the Netherlands. Various references to SIN-NL, see News

    April 2007: public register of medical errors and disfunctioning physicians in the Netherlands, proposed by Dutch Minister of Health, NRC Handelsblad 31.3.2007

    SIN-NL publishes IEU-alliance Manifesto 2007 on the occasion of the 50th anniversary of the EU, in order to improve the quality of healthcare in the EU, see International.

    Elsevier 15 March 2007: SIN-NL pleads for parliamentary inquiry and truthcommissions to examine medical errors
    SIN-NL starts Centre to report medical errors, see home and pressrelease under Netherlandsreact via info@sin-nl.org
    Medical errors and medical records, proposal for authorisation by the patient, March 2007 see News
    SIN-NL comments on Agreement Blame-free incident reporting 1 February 2007, see News

    Important developments in Patient Safety:
    January 2007: research shows that physicians exclude patients who are medically complex and litigious patients e.g. victims of medical errors, from medical care, article D.Studdert et al. USA, see international., see article by S.L.Weinstein M.D.USA and article by W.Cunningham New Zealand, international.

    November 2006: the Dutch Health Inspectorate adopts goals of SIN-NL:
    open and honest information and genuine remdial care to victims of medical errors.
    see Blamefree Reporting, under Netherlands.

    September 2006 : selfregulation physicians and hospitals fails, see News

    May 2006: companies are responsible for the wall of silence on medical errors by physicians.
    SIN-NL:
    Physicians, however have their own responsibility to inform their patients (Agreement Medical Treatment Law) and to report serious medical errors to the Health Inspectorate (Law on Quality)
    See J.Legemaate inaugural speech 10 th May 2006 Free University Amsterdam.
    For more information: see News and Netherlands.

    March 2006, major breaktrough: Harvard hospitals adopt goals of SIN-NL and IEU-Alliance, see International

    The doors to dialogue are open!
    SIN-NL had meetings with the platform patient safety, the Dutch Patient Consumers Federation, the Royal Dutch Medical Association, Royal Dutch Pharmaceutical Association, the association of Nurses, the scientific organisation of nurses LEVV,experts of patient safety, the research institute NIVEL, Members of Parliament, the Health Inspectorate, the Ministry of Health, Healthcare Insurers Netherlands, PGO, the Netherlands Organisation for Applied Scientific Research TNO, ICT experts and the media.

    SIN-NL was broadcasted on Radio 1, and published in the weekly of the Royal Dutch Medical Association as well as the daily newspapers Parool, NRC Handelsblad, Trouw, various regional newspapers, the weekly HP/De Tijd, the weekly Elsevier, the weekly NIW, magazine Linda, magazine Top Santé, the book "How do I survive healthcare?" by Alice Fuldauer (Dutch)and is mentioned on various websites.
    Moreover SIN-NL gave powerpoint-presentations to medical congresses in the Netherlands and abroad. Also SIN-NL was able to address the public at many congresses on the issue of patient safety and the need for improvement of the position of victims of medical errors.
    Apparently only external pressure can correct the failing self-regulation of the medical world.
    The support of the government, the politicians and the media is very important.
    SIN-NL will do its utmost best to improve patient safety and the position of the victim of a medical error, the iatrogenic patient in a structural way.
    See articles under News and Netherlands.


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    Summer Actionplan:measures to reduce medical errors, 24th of July 2007
    On July 30th 2007 the TV Newsprogramm Hart van Nederland SBS6 announced our Summer Actionplan.
    Summer or no summer, holiday or no holiday:
    Every day appr. 20 persons die and appr. 20 persons become disabled due to medical errors in Dutch hospitals.
    In spite of this emergency situation, the government, politicians and professional medical organisations take their summer recess..
    Therefore we call upon all professionals in healthcare to implement the following measures which will lead to an immediate REDUCTION OF MEDICAL ERRORS.
    We propose the following measures:
    1. Washing of hands against spread of MRSA
    2.Creation of correct medical records
    3.Discipline improvement: implementation of protocols and agreements
    4.Improvement of communication eg to obtain true informed consent
    5.Direct follow-up of alarming results of laboratory or examinations eg CT/MRI
    6.Arrangment of adequate aftercare after operation or after discharge from hospital
    7.Implementation of Tell and Repair principle:open, honest disclosure and repair of the damage of the medical error.
    Regularly possibly each week we will publish a short article on each of these measures.
    Summer or no summer: reduce medical errors!

    On the 6th of September we will close our Summer action with a short demonstration in Utrecht.



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    Call to physicians,nurses and hospitals, 8 July 2007
    Press release 8 July 2007.

    On the 6thof July 2007 we requested Mr P.Vierhout of the Association of Medical Consultants and Mrs J.Leemuis-Stout of the Dutch Association of Hospitals per open letter to meet and discuss open disclosure and adequate remedial medical care to victims of medical errors.
    We also explicitly requested Mrs M.Kaljouw of the Dutch Association of Nurses and Mrs J.LeGrand-van den Boogaard of the Dutch Expert Centre for Nurses to participate in the meeting.
    It is remarkable that both organisations of nurses immediately and completely acknowledged that victims of medical errors generally do not get honest information and do not get adequate remedial medical care.
    On the 12th of June 2007 after the congress of the Inspectorate of Healthcare, Mr Vierhout and Mrs Leemhuis agreed to meet and sofar did not contact us. Therefore we sent them our letter.
    The situation of medical errors is very serious: daily appr. 20 persons die and appr 20 persons become disabled due to medical errors in hospitals.
    Physicians and hospitals only reported 15 serious medical errors in 2006 to the Inspectorate of Healthcare, in spite of their legal obligation to report, art 4a Law of Quality of Health Care Institutions.
    A pause on patient safety activities due to the summer period is unacceptable.

    It is urgently necessary that all responsible stakeholders come together to discuss measures for improvement. We plead for implementation of the Tell and Repair Proposal. Please read the information on our websites: www.sin-nl.org and www.ieu-alliance.eu

    Sophie Hankes
    Chair SIN-NL and Chair IEU-Alliance




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    Reaction on plan on patient safety, June 12th 2007.
    On the patient safety campaign: Compliments! They’re becoming active!
    And what about the NPCF?

    Compliments to Minister Klink! For he is the first government and civil servant who is really dealing with the severe problems concerning medical errors. Apparently, he has managed to convince the responsible professional organizations that it’s been enough and that the number of victims of medical errors has to decrease.
    Yesterday, the 12th of june 2007, the managers of these organizations were on the podium at the IGZ conference on patient safety.:
    Pieter Vierhout, chairman of the Order of medical specialists (Orde van Medisch Specialisten)
    Joan Leemhuis-Stout, chairwoman of the Dutch Association Of Hospitals (Nederlandse Vereniging van Ziekenhuizen)
    Geert Blijham, chairman of the Dutch Federation of University Hospitals (Nederlandse Federatie van Universiteitsziekenhuizen)
    Marianne Kaljouw, chairwoman of the Nurses and Attendants Association (Vereniging van Verpleegkundigen en Verzorgenden)
    Professor Gerrit van der Wal, Inspector General of the Healthcare Inspection (IGZ) spoke to the above mentioned and even kind of interrogated them. He himself wasn’t spoken to.

    Of course, there is a dilemma in their position:
    Imagine that we ask them: Did you know that so many errors are made and people die or get injured in hospitals?
    If their answer is No, they are no longer credible. Partially because of 1999 To err is human.
    But if their answer would be Yes, then we would ask them why they haven’t put effort in improving the situation.

    It is very painful that many people in the Netherlands, and anywhere else for that matter, died unnecessarily or became disabled unnecessarily because of evitable medical errors. What a personal grief.

    Several critical notes can be made in this matter:
    -The recent plans concern only hospital care
    -When can we expect plans voor GP care, nursing home care, rehabilitation centers en home care, all part of a division of health care of which no statistics are available?
    -Why choose for a timeline of five years? This is arbitrary and much too long.
    -We plead for a zero-tolerance approach like it is already common in air traffic.
    -On what numbers are the proposed decisions based? We know that the published numbers are much too low; the real number of deaths because of medical errors is at least twice as high. This was confirmed again yesterday by Nico Oudendijk, substitute Inspector General of the Health Care Inspectorate.
    -Why does the Minister leave the execution of the plans up to the self-regulation of the professionals? J. Legemaate, lawyer of the KNMG, said to us in July 2006 that the self-regulation of medical professionals is failing and that only external pressure can correct the situation.
    -Minister Klink said he would take hard measures if necessary. We advise him to make sure that the Inspection will do what it is supposed to do, starting today.
    -Why is it that Minister Klink doesn’t take care of the shortage of employees of the Health Care Inspection? Nico Oudendijk told us that there’s not enough workforce in the IGZ to investigate individual cases and that he was aware of the fact that complaint commissions in hospitals are not really an option for patients. He even advises us to report to the police!
    -Not a single word was mentioned about the victims of medical errors as they exist today because of the present system.

    After Minister Klink’s speech SIN-NL climbed the podium and SIN-NL and asked for one minute for victims of medical errors. 500 persons including the leaders of Dutch health care institutions and professional organisations were present. We made the Minister compliments on his plans for the future. We asked to help the existing group of victims, who haven’t had true information nor repair treatment for years because of misplaced fear for legal procedures.
    We also addressed Iris van Bennekom, director of the NPCF (Dutch Patients Consumers Federation) married to a medical consultant: you do well, but you have to do better!
    It takes one to know one…..
    Than we handed a letter to Minister Klink with a short summary of the position of victims of medical errors and the necessity of improvement. We also gave him the legal proposal “Tell and Repair”as well as the 2007 Manifesto, the epidemiological survey of medical errors in Europe and the survey of activities of SIN-NL and the IEU-Alliance www.ieu-alliance.eu
    We requested a personal meeting.
    At the end of the conference we spoke to several leaders of medical organizations, Mr Vierhout, Mrs Leemhuis-Stout who both agreed to meet in the near future.
    Nico Oudendijk Deputy Inspector-General of the Inspectorate of Healthcare agreed to arrange a meeting within the near future on the position of the present victims of medical errors. He complained about a lack of personnel of the Inspectorate of Health Care which prevented thorough examination of individual medical errors.
    Our friends of the NPCF made a big step forward in their pressrelease the 12 th of June 2007:
    They adopted the most important goals of SIN-NL and the IEU-Alliance:
    -good aftercare after medical errors
    -information about what happened and what this means for the patient
    -information and advice about the necessary remedial medical care
    -information about the possibilities of complaints and legal procedures
    -information about measures which will prevent the reoccurrence of the medical error
    This complete change of strategy has surprised us in a positive way: thus the NPCF finally acknowledges the fact that victims of medical errors usually do not get honest information nor adequate remedial medical care.
    Has our correspondence with them during 1,5 years and 3 meetings have been of influence?
    It would have been honest of the NPCF to mention our existence, but the acknowledgment of the facts is the most important. And the NPCF should practice what it preaches:
    Help the many victims of medical errors who ask for years for honest information and remedial medical care!


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    Nivel/Emgo Report (25th April 2007) raises more questions, May 2007.
    Every single victim by medical errors is one too many.
    Even after a medical error avoidable damage can be prevented to iatrogenic patients.

    Prof.G.van der Wal, Inspector-General of the Inspectorate of Healthcare (www.igz.nl), presents in a video the following conclusions of the report:
    In 2004 76.000 persons were unintentionally harmed in Dutch hospitals by medical care. The question is, what is the definition of unintentional harm? Do they mean medical errors?
    30.000 persons were damaged by avoidable harm.
    6.000 persons were permanently damaged by avoidable harm.
    1735 persons died due to avoidable medical errors in Dutch hospitals.
    This means that the amount of persons who died by medical errors is twice as high as the amount of victims of road accidents. This appeared to be shocking!

    We certainly appreciate the openness of the involved hospitals to cooperate with this investigation. However we have found several limitations.

    - This research is initiated by the Association of Medical Consultants and is done by two medical research institutes, one originally intended for research on primary care (Nivel) and one connected to Free University Hospital VU Medisch Centrum Amsterdam (Emgo). This constitutes self-assessment, which per definition is not independent.
    - Prof. G. Van der Wal is not only one of the main researchers but also Inspector-General of Inspectorate of Healthcare. This causes a severe conflict of interests.
    - Apparently a medical ethical commission was not involved.
    - This report has been a written on the basis of retrospective research. This means that the objects and methods of research were defined retrospectively. Prospective research is more precise as definitions of objects and methods of research are formulated in advance. This method is more reliable.
    - The evaluation of the medical records was done by two consultants for each case. This is too restricted. In other examinations three consultants were involved with a backup of ten other persons.
    - The research was done by medical consultants of four medical departments; internal medicine, surgery, neurology and pediatrics. Other specialities were excluded. Thus this implies a limitation of medical expertise.
    - The research is only based on review of medical records. The researchers themselves acknowledge that 76% of the medical records of this research were not complete. This is a well known fact acknowledged by the top lawyer of the Dutch Medical Association Legemaate in his inaugural speech 2006. Also the Healthcare Inspectorate as well as the Medical Association of Consultants confirm that medical records are often inadequate.
    Reports written by patients were not included in this research. Several studies acknowledge the importance of reports of medical errors by the involved patients.
    - Terminal ill patients sometimes prefer to be with their family at home. Their deaths are not included in this research.
    - The research involves unintentional harm. This excludes intentional harm caused by deliberate refusal of neglect of adequate follow-up diagnostics and adequate remedial medical care to victims of medical errors. Several cases of inadequate hospitalisations leading up to six months without diagnostics nor treatment e.g. at the Free University Hospital (VU Medisch Centrum) are known to us.

    Conclusion SIN-NL
    On May 8th 2007 Chief-Inspector patient safety Jan Vesseur of the Inspectorate of Healthcare acknowledged that the numbers of victims of medical errors of the Nivel/Emgo report were incorrect, and should be at least doubled, in order to be realistic.

    The research of Nivel/ Emgo is incomplete, not independent and does not meet basic methodological requirements. Adequate independent and true scientific research to examine preventable damage in hospitals is urgently necessary. This is also necessary for medical errors in primary care, medical care in nursing homes, social legislation medical care and psychiatry. We need to know in order to be able to improve. Each victim of a medical error is one too many.

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    General amnesty: for victims and causers of medical errors?Ab Klink heads in the correct direction.
    Socrates: it is better to be a victim than a perpetrator.

    More than a year ago SIN-NL made its entrance and published about the horrible situation of medical errors and its victims. Almost nobody listened.
    The Nivel/Emgo report finally caused an uproar. On the 26 th of April2007 the Dutch parliament held an emergency debate and . Minister of Health Ab Klink will formulate emergency measures within 2 weeks.

    During our various discussions with physicians, psychologists, journalists and lay-persons the myth of the fiancial greed of victims of medical errors was mentioned. It is most necessary to correct this wrong image and describe the truth. What is the situation?
    Physicians exclude this group of innocent patients from honest information and adequate remedial care, in spite of their professional obligations base don the Law of the Medical Treatment Agreement. Victims of medical errors become –metaphorically- prisoners of physicians who either made the error themselves or who want to cover-up for their colleagues. This is the reason we use the term general amnesty.

    When do physicians understand that victims of medical errors are not their adversaries who only want to sue?
    This is the product of the imagination of physicians and hospitals and for them a reason and excuse to exclude victims of medical errors from honest information and remedial medical care. Apparently a simply phone-call from a physician to his/her colleague is enough to blacklist patients. In the mean time, victims of medical errors get non-useful examinations and even non-useful treatments and are misled, for years and years.

    Please be aware: scientific research by ao Marie Bismark, New Zealand, John Banja, USA as well as experiences of the Sorry Works coalition, USA and various American hospitals make the following clear:
    Victims of medical errors above and for all want to receive honest information about what happened and if the damage can be repaired via adequate remedial medical care. Furthermore the victims of medical errors want physicians to learn from their mistakes and that this error will not be repeated and inflicted upon other patients.

    Only when physicians and hospitals mislead the victims, keep them in suspense, and do not act according to their professional obligatoins, the sorrow and anger increase and make the victims consider litigation. Openness and honesty can prevent this. Thank G-d Minister Klink understands this.
    He ask to examine if physicians who do not inform their patients can be sued by the prosecutor. This justified. We already described the analogy with leaving a victim of a road-accident, without any assistance. This is a criminal offense.

    Abandonment by a physician of his patiënt by not informing him/her correctly and refusal to provide adequate remedial medial care after the error, in spite of his professional and legal obligations, can be considered as a criminal offense. Colleagues cover-up, because they can also make an error today or tomorrow.
    This way victims of medical errors are condemned to a life-sentence metaphorically-and become prisoners of physicians, without any form of trial, based on self-protection and a myth. One physician even said to us: your situation is comparable to prisoners in Guantanamo-bay.

    This cannot continue. Beware: victims of medical errors are innocent fellow human beings who had the bad luck to struck by a medical error.
    These “prisoners of the physicians” are entitled to an immedeate general amnesty.
    Physicians you should liberate them today! If you do not so voluntarily, the authorities will have to force you.
    We are thinking about our attitude towards the group of physicians who has caused so much preventable and avoidable sorrow. Should we give them general amnesty?
    Let them first show understanding and regret. This is the least.

    We call upon all conscientious physicians to change their ways.
    Victims of medical errors are not adversaries who run immedeately to court. Please give the victims of medical errors honest information and adequate medical care, acoording to your professional and legal obligations, and according to the “Tell and Repair” protocol, see speech G. van der Wal Inspector General of the Health Inspectorate 23 november 2006, see www.igz.nl which is based on the Harvard Consensus Report (2006) When things to wrong: responding to adverse events, see international.
    You can learn from your errors and from your patients and rebuild the confidence.: information, transparancy and respect in stead of mistrust.

    Minister Klink: we do not strive for legal procedures, which are hard to win due to lack of objective medical reports and which are only advantageous for the lawyers.It might indeed by wise to examine if directors of hospitals can be held accountable for medical errors, and if the financial arrangments for serious victims of medical errors can be improved. Legal procedures do not have our main attention.

    Toppriority is and should be to arrange information and adequate remedial medical care for the victims and their families. Honesty improves the relation between physicians and patients and will enable physicians to learn from their errors.
    You are heading in the right directions, listen to the victims, start the dialogue.
    A lot has to be done, please hurry to limit and avoid preventable sorrow.
    Hillel said: if not now, when?







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    How do I survive healthcare? Alice Fuldauer, april 2007
    Finally the long awaited book about medical errors and patient safety in the Netherlands has been published: Hoe overleef ik de zorg? How do I survive healthcare? by Alice Fuldauer.
    Alice Fuldauer has written about the serious situation in a style which is clear and well readable.
    She discusses various subjects in eight chapters: the epidemiology of medical errors, general practioners, consultants, medication, plastic surgery, litigation, the health of the Dutch and patient safety in the future.
    Main theme is certainly the unsafety of healthcare in the Netherlands, how to deal with this situation and how to improve it. Various experts explain their view on the need and ways of change. It is discussed that the Health Inspectorate lacks inspectors and that some of their research on location is substandard.
    She gives sad examples of victims of medical errors and explains the difficult position of the patient. The tragic death of baby Dimitri is briefly descibed.
    SIN-NL finds it remarkable that the Dutch Consumer Patient Federation NPCF is not active to improve the position of victims of medical errors or patient safety. Apparently the NPCF receives financial support from the pharma-ceutical industry . SIN-NL wonders what the true goals are of the NPCF.

    She indicates at various places that physcians generally do not inform victims of medical errors that an error occurred, for fear of litigation, inaugural speech J.Legemaate, 2006.
    It was apparently too shocking to publish that as a consequence of not informing these patients, physicans generally do not provide victims of medical errors with adequate follow-up diagnostics nor with adequate remedial medical care to mitigate the damage of the error, as this would thus inform the patient.
    SIN-NL emphasizes that Karl-Heinz Florenz then Chair of the Committee of Healthcare, Environment and Foodprotection of the European Parliament has confirmed this June 2006.
    She quotes Johan Legemaate toplawyer of the Dutch Medical Association who stresses that the giving of information and direct remedial care to limit the damage of a medical error belongs to the professional
    obligations of physicians.
    Alice Fuldauer pleads for improvement of the position of the patient and for openness when a medical error occurrs.

    At the end of her book she publishes a survey of literature and organisations in healthcare, in order to enable the public to make more conscious and better choices concerning their health and safety.
    Alice Fuldauer makes references to various reports which SIN-NL and the IEU-Alliance provided en mentions our organisations several times. She does publish the shocking figures of our epidemiological survey,2006:
    appr.20 persons who die and appr 20 persons per day who become disabled by medical errors at hospitilisations in the Netherlands.
    She also mentions the amount of appr.450.000 victims, nearly half a million people, in the EU, who die or become disabled each year.

    We compliment her with her publication and are convinced that it is a worthy contribution to the improvement of patient safety in the Netherlands. Warmly recommended.

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    Medical errors and medical records, proposal for change, March 2007
    Proposal for authorisation of medical records by the patient.

    As acknowledged by Prof. Legemaate of the Royal Dutch Medical Association (KNMG) in his augural speech May 2006, Free University Amsterdam, physicians generally do not inform their patients about the occurrence of a medical error.
    This implies that the medical records are often not complete or not completely correct, in order to conceal the medical error as much as possible.
    For the patient/victim of the medical error it will thus be very difficult to prove the error.
    A report by the Inspectorate of Healthcare February 2007 and the Nivel/Emgo Report on adverse events- medical errors- in Dutch Hospitals April 2007 confirmed that many of the medical records are inadequate.

    Physicians also register-unjustly- often in the records that they informed the patient extensively or that the patient refused or requested certain examinations. Sometimes we even find derogatory remarks about the patient.

    After the occurrence of a medical error, the patient/family members should request a copy of their medical records as well as the nurses records as soon as possible.

    In order to avoid any misunderstandings or deliberate changes we plead to install a standard procedure for medical records:
    -at the end of each consultation the physicians hands a copy of the report of the consultation in order to enable the patient to check and correct it.
    -the report of a medical consultation is only valid and has legal status when the patient has put his signature of approval under it.
    -likewise for all medical records by nurses and other healthcare professionals.
    In addition: no correspondence without authorization( signature) of the patient.
    Too often letters which contain incorrect information have been sent by physicians, assuming permission by the patient. No permission can be assumed automatically. No area of activities in our society permits professionals to write letters without the consent of the individuals involved. The privileges which the medical profession has assigned to itself are incorrect and have been unjustly obtained. Transparency requests prior consultation and authorization of/by the involved patient. All letters which a medical professional sends should be authorized by a signature of the involved patient.





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    Agreement Blame-free Incident Reporting 1 February 2007: why blame-free? Part 1.
    February 1st 2007 an agreement on Blame-free Reporting was signed by the Dutch Medical Association, the Association of Medical Consultants, the Dutch Association of Hospitals, the Dutch Federation of University Hospitals, the Association of Nurses and Caretakers, and the Dutch Federation of Patients Consumers.

    SIN-NL asks the following questions:
    Does this document mention the legal obligation of physicians, nurses etc mentioned in art 4a of the Law on Quality of Healthcare Institutions to report serious medical errors to the Inspectorate of Healthcare?NO…
    Does this document mention the legal obligation of physicians, nurses etc in the Law on Agreement of Medical Treatment to inform patients of the occurrence of a medical error?NO..

    In whose interest is this document? This document is in the interest of the reporter ….
    Who is the reporter? The physician or nurse who caused the error…
    What is reported? The incident…
    What is an incident? According to the document: everything what was not planned…
    Is the expression “medical error” mentioned? No…
    Is the expression “damage by medical error” mentioned? No…
    Are the words “victims of medical errors” mentioned? No…
    Are the victims of medical errors allowed to view the reports? No…
    Who examines the correctness of the reports? Unknown….

    Were victims of medical errors involved in the development of the document? No.*
    Has the document been signed by victims of medical errors?No*.
    Is the document in the interest of victims of medical errors?No.

    Please notice that neither the Department of Health, nor the Health Inspectorate nor the Public Prosecutors Office signed this document.

    Is there anything positive in the agreement? If so, what? Yes, fortunately:
    -It acknowledges that the efficiency/effectivity of the FONA and MIP-committees is limited.
    -it acknowledges the importance of the collection and analysis of medical errors at a national level and it acknowledges the importance of a national reporting system at a decentral level.
    -it wants to stimulate reporting and mentions the possibility to address thos who do not fulfill their duty to report
    -it acknowledges the possibility of intention and gross negligence and mentions the possiblity of measures. It is however unclear which measures.
    -one acknowledges the responsibility of the institution and the physician or nurse to register medical errors with damage in the medical report of the patiënt. However sanctions are not mentioned, if they do not report the error.
    Moreover SIN-NL strongly objects the fact that victims of medical errors are forbidden to read the report. The victims are directly involved and capable to describe the error and the damage…
    Conclusion: this is typically a document ABOUT and WITHOUT the directly involved: the vcitims of medical errors!
    The physcians/ the offenders are safe, the victims of medical errors not….
    Personal responsibility is a moral obligation according to SIN-NL.
    If not now, when...?

    *as far as SIN-NL has been informed.

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    Agreement Blame-free Incident Reporting 1 February 2007: why blame-free? Part 2.
    In appendix 1 of the Agreement Blame-free Reporting we read two important statements:
    1. December 2006: the Minister of Health acknowledges that fear of legal procedures is one of the impediments for reporting of medical errors, and thus also for informing the patients according to SIN-NL and J.Legemaate, lawyer of Dutch Medical Association in his Inaugural Speech, Free University Amsterdam 2006.

    2. October 2006: the Inspector-General of Healthcare states that the system of Blame-free reporting has to be 100% safe. This means that no measures can be taken against individuals:
    Not against he/she who reports and not against others involved in the incident.

    SIN-NL: this means that all involved in the incident- medical error- should be safe, thus also the victims of medical errors!
    We emphasise that victims of medical errors become involved in an error, not by their free will. They were not safe. Moreover: those who caused the medical error certainly do take measures against these innocent victims: no information, no registration in the medical records, no adequate follow-up diagnostics, no adequate remedial medical care.
    Medical errors make the victims per definition reporters against their will.
    Their simple existence means evidence of medical errors.
    When they choose to be silent, their suffering is silent and usually unnoticed.
    When they have the courage to go to a medical disciplinary board or the media, they become a sort of whistle-blowers, with several serious consequenses e.g. exclusion from medical care, see International.
    SIN-NL strongly pleads to give special protection and extra careful medical diagnostics and remedial medical care, as stated in the Harvard Consensus Report, march 2006, see News.
    This is also the opinion of Harry Molendijk, Chair of the Platform Patiënt Safety, in our discussion on May 9th 2006. Unfortunately he did not put his words into action, sofar.

    Blame-free reporting means safety for the reporting physician or nurse.
    However: personal responsibility is a moral obligation.
    According to SIN-NL blame-free reporting should mean:
    Extra and special safe healthcare for the victims of medical errors.


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    2007: YEAR OF AND FOR VICTIMS OF MEDICAL ERRORS, jan. 2007
    SIN-NL declares 2007 as the year of and for victims of medical errors.

    Physicians, nurses, hospitals,risk- insurers, healthcare-insurers, Health Inspectorate, professional medical and hospital organisations, politicians and the media:
    Take your responsibility:
    -inform the victims of medical errors and/or members of their family fully and correctly
    -give adequate follow-up diagnostics and remedial medical care to repair the damage
    give continuity of care and give access to genuine medical care
    -give respectful and timely financial compensation.

    Above all: be open and hones to the victim and his/her members of the family according to your obligations of the Law on Medical Treatment Agreement and
    Report medical errors according to your obligations of art 4a of the Law on Quality in order to ensure examination and analysis and to develop systems of prevention of medical errors.

    We strongly plead to install special Truth commissions to examine the medical errors and acknowledge the damage and sorrow which has been caused to the victims.

    Please send your email to info@sin-nl.org with the text:
    I support the year 2007 as year of and for victims of medical errors.



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    Conferences patient safety and reporting medical errors, nov.2006
    Presrelease November 20, 2006
    Conferences on patient safety and reporting of medical errors.

    Elections in the Netherlands
    The Dutch choose, physicians prefer to be silent.

    Since last week many medical errors occurred in hospitals in the Netherlands.
    Appr. 20 persons died and appr. 20 persons became disabled per day.(1)
    We do not know who, in which hospital and which physicians are responsible.
    In spite of the legal obligation to report medical errors to the Health Inspectorate ( art 4a of the Law on Quality) there is serious underreporting.(2)

    November 23, 2006 there will be a national conference in Rotterdam on patient safety.
    However no patient or patient-organisation has been invited to speak.
    November 24, 2006 there will be a national conference in Utrecht on reporting medical errors.
    The main goal is to promote the willingness of physicians and nurses to report.

    Why do physicians or nurses disobey the law?
    Do you think the enormous amount of medical errors and thus victims is acceptable?
    Politicians and media: be active and publish in order to call upon the medical profession to act according to their responsibilities and improve patient safety.


    1.NPSA Building a memory:Preventing harm,reducing risks and improving patient safety,
    UK 2005 p.53
    2.Bles, W.van der , ‘Artsen moeten fouten erkennen’uit Trouw 14.6.2006 Dutch Newspaper
    3.Conferences: www.platformpatientveiligheid.nl



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    Selfregulation fails, insurance and accreditation institute owned by medical field, sept.2006
    Sept 15th 2006 the Algemeeen Dagblad,, a large Dutch newspaper published an article which stated clearly that many hospitals register medical errors incorrectly. This makes it almost impossible to analyse the errors and learn from them
    This year 2006 the IEU-Alliance developed a survey of medical errors: epidemiology, see under News, based on data from the National Patient Safety Agency UK 2005:
    -at 10% of hospitalisations medical errors occur, 1% is serious, leading to death or disability.
    This means that at 1 in 1000 hospitalisations either a person dies or becomes disabled.
    If severe damage would be caused by an industrial product, this product would be taken of the market, without delay.
    -in the Netherlands appr. 8000 persons die and appr. 8000 persons become disabled due to medical errors per year,
    which means that appr. 20 persons die and appr. 20 persons become disabled PER DAY!
    -there is international consensus that 50% of medical errors are preventable, see a.o.
    report by Rein Willems, President-Director of Shell Netherlands, report 2004.
    But:
    Medical errors are not registered correctly,nor analysed nor learnt from. At present there is no system of prevention of medical errors.
    How is this possible?
    -According to Prof.J.Legemaate (inaugural speech May 2006) the insurance companies doe not allow physicians to inform patients that a medical error occurred, for fear of legal procedures.
    -please note that physicians have their own legal obligation to inform their patients according to the Law on the Agreement for Medical Treatment.
    -moreover: the insurance company Medirisk is owned by 74 Dutch hospitals.
    Thus the unethical obligation to be silent about medical errors is imposed by the hospitals themselves!
    -also the accreditation of hospitals ( a kind of approval which shows that there is a culture of improvement and justified confidence in the quality of the institution)is in the hands of the NIAZ, an organisation which was founded in 1998 by the Association of Medical Consultants, the Association of Hospitals , the Dutch Federation of Academic Medical Centers: the medical field!
    -in april an agreement to cooperate was made between the NIAZ and Medirisk.
    -just as an illustration: the Radboud Hospital with its department of cardio-surgerywas accredited and still it disfunctioned many years until the Health Inspectorate shut it down temporarily in 2006 after many patients died unnecessarily.

    Conclusion:the self-regulation of the medical field, also known as a state within a state, fails
    enormously, as long as thousands of people die and become disabled by medical errors.
    And…physicians often do not give adequate remedial care to victims of medical errors, for fear of litigation. This has recently been confirmed in writing by Karl-Heinz Florenz, Chair
    Commission Environment, Foodprotection and Healthcare of the European Parliament.

    External independent examinations are urgently necessary to improve patient safety and the position of the iatrogenic patient.


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    Physicians prefer non-disclosure, study reveals, august 2006
    Physicians prefers non-disclosure at hidden medical errors.
    Source: NRC-Handelsblad August 17th 2006 (Leading Dutch newspaper)

    50% of medical consultants in the USA and Canada would not disclose a medical error which the patient can hardly discover.
    This is written in a study in which more than 4000 physicians were asked how they would react in case of hypothetical errors (Archives of Internal Medicine, August 14th 2006).

    The situation in which they (39%) did not disclose most often:
    “You give a patient who has high blood pressure a new medication, which has a side-effect that the potassium in the blood levels will rise. However you forget to ask for the potassium levels at the laboratory. In the mean time, these levels rise so strong that the patient gets life threatening heart rhythm disturbances.

    Almost all physicians would tell the patients that a sponge was left in their body after the operation. But they would rather not use the word “error”.

    Comment:

    From a very direct source we know about a similar case in which a patient with high blood pressure was administered strong medication. This had as a consequence that severe kidney dysfunction developed, necessitating admission and treatment at the Intensive Care-Unit.
    Only due to the fact that a member of the family searched and found another consultant who was willing to save the life of the patient, the patient survived.
    Later at the disciplinary board meeting, however the second consultant who had saved the life of the patient, did not remember anything….
    The cardiologist who was responsible for the medical error, never disclosed the error to the patient and was acquitted from any blame.
    Is this ethical?


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    Prevention of medical errors and money, june 2006
    RIVM:prevention not of interest to physicians and hospitals for financial reasons, June 2006

    Press-release 29.6.2006
    The State Institute for Public Health and Environment (RIVM):
    Reason to worry about the health of the Dutch population.

    The Ministry of Health of the Netherlands strives that the Netherlands should be back in the top five of most healthy countries of Europe.
    Apparently the state of health of the Dutch people has declined as the Netherlands are now somewhere in the middle of the European ranking-list concerning the life-expectancy.
    This is written in a report of the RIVM which was presented on the 28th of June 2006.
    The RIVM pleads for more measures of the Dutch government to prevent diseases and should teach healthy lifestyle. According to the Minister of Health Hans Hoogervorst it should be possible to have the Netherlands back in the top five.
    So far the Dutch Parliament has voted against proposals to discourage smoking and drinking alcohol. Hoogervorst expects that it will be necessary for the Parliament to prescribe unpopular measures( eg a ban on smoking in cafés).
    The life-expectancy of Dutch men and women rose slightly, as data from 2003 show.
    However obesity, over-use of alcohol, unhealthy diet and smoking reduce the life-expectancy.

    According to the RIVM there is too little emphasis in the Netherlands on the prevention of diseases, due to the system of organisation of health care.
    Physicians and hospitals have no financial interests to pay a lot of attention to prevention.

    Source:ANP
    Author:News Editors Elsevier Healthcare

    SIN-NL comment:
    The reduction of medical errors is clearly a matter of prevention.
    Is MONEY a motive for physicians and hospitals to impose the wall of silence on the emergency-situation of medical errors in the Netherlands :
    -20 persons die each day
    -20 persons become disabled each day
    Is MONEY more important than patient safety?

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    Doors to dialogue are open, june 2006
    The doors to dialogue are open: participation to conferences and symposia, 2006
    -EPN: introduction of electronic medical records
    SIN-NL mentioned that it was important that the present medical records and future electronic medical records are 100% true and can be corrected by the patient.
    -ZonMw:measurement of patient-satisfaction
    SIN-NL was offered to give a public reaction and appreciated the initiatives to measure patient.satisfaction. However SIN-NL pointed out that one has to be realistic:20 persons die and 20 persons become disabled each day in the Netherlands. This is an emergency situation to be improved urgently. SIN-NL called upon the top-managers:no words, but deeds!
    -Inspectorate of Healthcare:patient safety
    SIN-NL participated actively in workshops and pleaded for cooperation with all involved to improve patient safety. The inspectors of the Health Inspectorate responded respectfuL During the plenary session SIN-NL was allowed to compliment Prof Diana Parker (Manchester, UK) with her excellent analysis of methods of approach towards medical errors by hospitals. SIN-NL spoke out that iatrogenic patients are excluded from genuine medical care, for fear of litigation. Prof Parker therefore suggested to study the approach of physicians and hospitals.
    SIN-NL was impressed by the speech of Dpt Inspector-General Nico Oudendijk and the involvement of the participants to the conference to improve patient safety. N.Oudendijk emphasised that the Health Inspectorate has choosen for a revolution:
    from "of, by and in