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Reports on patient safety

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WHO 2005 Governance of Patient Safety (3.35mb)

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

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Emergency plan for medical errors, 25th November 2007


An emergency plan has been developed, due to the fact that the Inspectorate of Healthcare in the Netherlands refuses to examine medial errors and to help victims of medical errors. On the 7th of November 2007 the Assocations of Medical Consultants, the Hospitals and Nurses in the Netherlands have acknowledged that physicians give almost no honest information to victims of medical errors and refuse to give them adequate follow-up diagnostics and remedial medical care. These associations also acknowledged that this refusal is a criminal offence.

In a recent meeting with the Inspectorate of Healthcare it became clear that:
  • this organisation refuses to examine the present medical errors
  • this organisation refuses to prosecute physicians who refuse medical assistance to victims
  • this organisation focuses for patient safety only on the future.

    Conclusion:
    The Inspectorate of Healthcare refuses to examine criminal offences and to prosecute the perpetrators. Apparently physicians are above the law. Please be aware that it is a fact that there are thousands of medical errors per year, thousands of victims per year and the Health Inspectorate refuses to examine. Suppose the police would refuse to trace traffic perpetrators who leave victims unattended after an accident, so-called “hit and run”. This is a well-known criminal offence.

    SIN-NL developed the following emergency plan:
    1.Website: publication of photo’s and a black list of physicians who deliberately refuse honest information and remedial medical care to victims of medical errors, in spite of their obligation according to the Law on Agreement of Medical Treatment.

    2.Proposal to add as a criminal offence in the Code of Penal Law: refusal of honest information and remedial medical care to victims of medical errors, analogue to the “hit and run”criminal offence art 7 in the Law of Traffic and implementation of Tell and Repair.

    3.Request to the Council of Research of Safety:
  • to examine the seriousness and quantity of medical errors
  • to examine the refusal of adequate information and care to victims of medical errors
  • to formulate recommendation to improve the situation.

    4. Request to the Ombudsman to examine the refusal of the Inspectorate of Healthcare to inspect the structural refusal of honest information and adequate care by 5 hospitals to a victim of a medical error.

    5.Add to the Law of Agreement on Medical Treatment:
  • Medical records are only valid after written authorization by the patient.
    *sanctions for not handing over the medical records within a reasonable period of time
    *the right for patients to receive their ICD-10 Codes of their illness, as well as copies of all bills of the physicians and hospitals.

    6. Installment of an Ombudsman to assist victims of medical errors, with the authority to interfere immediately at the refusal of adequate honest information and care to victims of medical errors which can cause maltreatment and manslaughter.

    7.Installment of an independent Institute for victims of medical errors, function:
    Registration, examination and prevention as well as arranging honest information and adequate remedial medical care

    8. Parliamentary Inquiry and instalment of Truth commissions.
    Information:

    Sophie Hankes LL.M.
    Chair SIN-NL www.sin-nl.org and IEU-Alliance www.ieu-alliance.eu
  • Solutions
    SIN-NL is concerned about iatrogenic suffering which relates to medical errors and disorders etc.,caused inappropriately by any clinician through his/her manner, diagnosis or treatment.
    SIN-NL strives for dialogue with all involved.
    SIN-NL stands for Sufferers of Iatrogenic Neglect -Netherlands.
    SIN-NL is Chair of the Iatrogenic Europe Unite-Alliance www.ieu-alliance.eu

    The aims of SIN-Netherlands are:
    -honesty about medical errors by physicians, nurses and all involved from the medical world.
    -openness and providing information about the medical error and the consequences to the patient and the family of the patient.
    -providing genuine medical care, diagnostics and treatment in consequence of the medical error to repair the damage and to restore the quality of life, as far as possible.
    -financial compensation for victims of medical errors, based on national tariff, decided by mediation.
    -registration, analysis and research of medical errors to achieve prevention.
    All goals to be regulated as statutory obligations.

    Appeal! 2007 Year of and for victims of medical errors.
    Please report medical errors to info@sin-nl.org

    Did the physician inform you that "something went wrong"?
    Did the physcian try to repair the physical damage?
    Did the physician register the error in the medical records or did he not mention it?
    Did the physician contact the Board and the Health Inspectorate?
    Or was the physician silent about the error?
    Did you find another physcian in the Netherlands or abroad who helped you?
    Or is it difficult for you to find adequate medical care, after the medical error?
    Did you file a complaint at a Medical Disciplinary Court or at the Health Inspectorate?
    Did you contact newspaper-, magazine-, radio- or television-journalists?
    What are your experiences?

    The situation of medical errors is serious, in quantity and in quality, see this website.
    SIN-NL tries to improve this situation in a structural way.
    Your experiences and information can help us to achieve our goals to improve patient safety and the position of victims of medical errors.
    Please mail to: info@sin-nl.org

    Click please on the solutions:

    Indications for medical errors

    Survey medical errors Europe and worldwide

    Year 2007 of and for victims of medical errors

    Manifesto 2007

    Medical records: proposal for change

    Tell and Repair legal proposal

    Summer action plan 2007

    Emergencyplan for medical errors

    Patient inform yourself

    Questions to physicians

    Even when you are ‘an experienced’ patient, it might be worthwhile to prepare your questions in case of an unexpected diagnose or course of events after treatment, eg a medical error.
    Start asking questions while in the office—even if you know nothing about the condition that you have just been told about. Ask:
    What’s the cause? (How did I get this?)
    How will this condition affect my life?
    How will my condition affect others?
    Do you have a cure?
    How long must I take this treatment?
    If you had my condition what would you be asking right now, Doctor?
    If you had this condition who would you go to for care? I can afford to travel anywhere.
    Are there doctors holding opinions that disagree with your approach?
    Do you have anything I can read? Any scientific reference papers?
    Do you have other patients who have similar problems that I can talk to?
    Do you have any patients that you have treated who would share their experiences with me?
    Does diet and lifestyle have anything to do with this problem?
    Could you please give me your information in writing?
    When will we have the next appointment?

    Information to physicians, nurses and all who work in medical care.


    This website, SIN-NL and the Iatrogenic Europe Unite-Alliance www.ieu-alliance.eu are the initiative of a victim of a medical error.
    It is the intention of this website to promote openness and honesty about medical errors.
    Also we want to promote that physicians will give honest information and adequate remedial medical care to victims of medical errors.
    The tone of the website is analysing, realistic and influenced by the horror of the harsh facts.
    The website has no intentions to scare or to evoke resistance.
    We ask for honesty, openness and courage about medical errors.
    We want to improve the quality of medical care together, with great urgency.
    Please put yourself inthe position of a victim and prevent further unnecessary harm.
    This will be of benefit to us all. See further in the Introduction.

    SIN-NL is concerned about iatrogenic suffering which relates to medical errors and disorders etc.,caused inappropriately by any clinician through his/her manner, diagnosis or treatment.
    SIN-NL strives for dialogue with all involved.
    SIN-NL stands for Sufferers of Iatrogenic Neglect -Netherlands.
    SIN-NL is Chair of the Iatrogenic Europe Unite-Alliance www.ieu-alliance.eu
    SIN-NL is partner of Patient Safety.com.an American organisation for victims of medical errors

    The aims of SIN-Netherlands are:
    -honesty about medical errors by physicians, nurses and all involved from the medical world.
    -openness and providing information about the medical error and the consequences to the patient and the family of the patient.
    -providing genuine medical care, diagnostics and treatment in consequence of the medical error to repair the damage and to restore the quality of life, as far as possible.
    -financial compensation for victims of medical errors, based on national tariff, decided by mediation.
    -registration, analysis and research of medical errors to achieve prevention.
    All goals to be regulated as statutory obligations.

    NEWS
    2/05 | Questions to your doctor in case of unexpected developments eg a medical error
    see Solutions

    23/04 | Report Conference Victims of Medical Errors April 23rd 2008
    see News

    11/04 | More information on the Conference to improve the situation of victims of medical errors
    see News

    04/04 |
    After weeks of silence
    SIN-NL and the IEU-Alliance finally received the invitation. As a result of our common historic meeting on the 7th of November 2007 the Dutch Association of Hospitals, the Dutch Association of Nurses and Caregivers and the Dutch Association of Medical Consultants will organise a conference about the improvement of the position of victims of medical errors on the 23rd of April 2008.
    Further information will follow as soon as possible.

    March 16th 2008: publication of Black Book of Victims of Medical Errors in Dutch.
    Translation in English as soon as possible.


    March 10th 2008: progress on Tell and Repair legal provision, see News.

    January 16th 2008: SIN-NL discusses legal provision Tell and Repair with Minister Klink
    and presented a letter to him. Read the letter to the Minister of Healthcare, please






    In loving memory of Regina Zwart
    13th November 1919-14th August 2002
    physicians and central medical disciplinary court negligent




    In loving memory of Lubertus Hankes
    25th february 1919-14th January 2000


    murdered by dr. Z. Zylics 14 th January 2000
    see black list of physicians and Netherlands.


    Clarification that my father Lubertus Hankes was murdered by a physician.

    The use of the words: murdered by a physician raises questions, understandably.
    These words however are not used frivolously, on the contrary.
    Also the fact that my father was 80 years old when he died, makes people think:
    well that is a respected aged. So this man should accept to die.
    The issue at stake here however is the fact that neither my father, nor I asked to terminate his life by palliative sedation.
    My father was not in pain and did not suffer.
    Dr Zylics of the hospice Rozenheuvel brought my father into coma by palliative sedation without my fathers consent and without my consent. He did not give him fluid nor food.
    After my father was in coma for about two days, he gave my father an injection with muscle relaxant medication due to the fact that my father started to cough.
    Dr Zylics did not inform me that this injection would hasten my fathers death.
    Thus the life of my father has been terminated on purpose, without my fathers consent and without my consent. This is the reason I write that my father was murdered.
    Marjoleine de Vos wrote an impressive article about my fathers wish to live in the daily newspaper NRC Handelsblad of October 25th 1999. It is also published in her book:
    Nu en altijd:bespiegelingen. Hoofdstuk 2: Hij wil niet sterven pag.13 t/m 16
    ISBN: 9053339817
    Publisher: Prometheus/NRC Handelsblad Amsterdam/Rotterdam 2000

    Sophie Hankes.


    The blacklist of physicians was published on our website to expose physicians who refuse to give honest information and honest remedial medical care to victims/family members of medical errors.
    Please note that physcians have decided first to make a black list of victims of medical errors and expelled victims from access to healthcare. Physicians have decided not to respect their duty of continuity of care. This is contrary to the fundamental rights of access to adequate healthcare, see 'the other" black list. We removed the blacklist of physicians on March 2nd 2008 due to a boycot by the associations of medical consultants, nurses and hospitals.

    2008 : no words but actions, SIN-NL will focus on medical errors of general practitioners.

    January 10th 2008:
    Baby Ashana died unnecessary because four general practioners refused to refer her to the hospital. On the 10th of January 2008 the Central Medical Disciplinary Court in the Hague discussed the case. Grandfather Peter van den Berk was present and SIN-NL assisted him.
    SBS 6 Heart of Holland broadcasted an interview with the grandmother of Ashana and with SIN-NL,
    see in the media.


    Ashana
    September 2, 2002 - March 2, 2003


    January 7th 2008: the 'other' blacklist of patients, see News.
    January 7th 2008 Algemeen Dagblad, see SIN-NL In the media, News
    7 years refusal of honest information and genuine remedial medical care, in spite of disability caused by medical error.

    2008 year of transparency and innovation for victims of medical error
    On the 19th December 2007 Nico Oudendijk Deputy Inspector General Inspectorate of Health Care has signed the Tell and Repair legal proposal in presence of John Kleijn of Dimitri.nu, Sophie Hankes and Peter van den Berk, SIN-NL / IEU-Alliance.



    Meeting November 7th, 2007.
    Association of Medical Consultants, Dutch hospitals and Dutch nurses and caregivers agree to formulate a proposal to improve information and remedial medical care to victims of medical errors. This proposal shall be presented by the Associations before March 15, 2008.



    Standing fltr: John Kleijn (Dimitri.nu), Marian Kaljauw (VenVN), Gitta Gallé (NVZ), Harry van Hulsteijn (Association of Medical Consultants), Ria van de Reep (Dimitri.nu). Sitting fltr: Trudy Boshuizen (NVZ), Hedwig Slot (Association of Medical Consultants),
    Sophie Hankes (SIN-NL/IEU-Alliance).





    17 October 2007 :
    Succesful meeting with organisation of Medical Consultants about the Tell and Repair legal proposal, based on the Harvard report, 2006. New meeting in November 2007.
    Further information will follow.

    Let doctors pay for their medical errors, and not the patients! see news.

    SIN-NL on website Tros Radar, 10th september 2007
    MAJOR BREAKTHROUGHS November and December 2007



    Nico Oudendijk Deputy Inspector General Inspectorate of Health Care receives the Tell and Repair legal proposal from Sophie Hankes SIN-NL / IEU-Alliance, 6th september 2007 and has signed this legal proposal on the 19th of December 2007.


    On the 6th of December 2007 the second largest newspaper of the Netherlands publishes an article on the black list of physicians of SIN-NL on the front page and on page 3, stressing the need for full and open disclosure as well as adequate remedial medical care after medical errors.


    The organisation of Medical Consultants acknowledges in public debate 3rd september 2007 that the aftercare to victims of medical errors is practically zero; thus that physicians do not inform victims in an honest and open way, nor give adequate remedial medical care to repair the damage of the error.


    6th september 2007 the Inspectorate for Healthcare confirmed in a meeting with SIN-NL/IEU-alliance that the aftercare of physicians to victims of medical errors is indeed zero, see News.
    Demonstration to promote "Tell and Repair" as final measure of Summeraction plan succesful, broadcasted on television.

    3rd Sept 2007 Debate on Nivel report on medical errors without representative of victims.
    No debate but propaganda, Nivel reports: families of 1735 deceased victims of medical errors not informed,
    see Netherlands.

    September 2007, CALL FOR MEETING SUCCESFUL:
    the Dutch Association of Hospitals, the organisation of Medical Consultants, the Association of Nurses and Caregivers and the Center of Nursing Expertise agree to meeting with SIN-NL/IEU-Alliance to discuss improvement of the position of victims of medical errors,
    see News.

    SIN-NL / IEU-Alliance offers Tell and Repair proposal to Minister Klink. 12-06-07
    Click here to see the photo


    Appeal! 2007 Year of and for victims of medical errors.
    Please report medical errors to info@sin-nl.org

    Did the physician inform you that "something went wrong"?
    Did the physcian try to repair the physical damage?
    Did the physician register the error in the medical records or did he not mention it?
    Did the physician contact the Board and the Health Inspectorate?
    Or was the physician silent about the error?
    Did you find another physcian in the Netherlands or abroad who helped you?
    Or is it difficult for you to find adequate medical care, after the medical error?
    Did you file a complaint at a Medical Disciplinary Court or at the Health Inspectorate?
    Did you contact newspaper-, magazine-, radio- or television-journalists?
    What are your experiences?

    The situation of medical errors is serious, in quantity and in quality, see this website.
    SIN-NL tries to improve this situation in a structural way.
    Your experiences and information can help us to achieve our goals to improve patient safety and the position of victims of medical errors.
    Please mail to: info@sin-nl.org

    Powerpoint presentation on patient safety and medical errors.



     





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