SIN Nederland

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

Netherlands

Netherlands

Report First National Conference for Victims of Medical Errors April 23rd 2008

Open letter to Dr. Harry Molendijk, Chair Platform Patient Safety, 22nd Jan.2008

Indications for medical errors, January 2008.

Dr Zylics killed my father.after medical error in the UMC Utrecht, 14 jan. 2008.

The 'other' blacklist. 7 years no care in spite of disability by medical error, 7th Jan. 2008.

Nivel report on medical errors: the victims and families of the deceased are NOT informed,sept.2007

No debate but propaganda on Nivel report on medical errors, 3rd sept. 2007

Press release:Nivel/Emgo report more questions and call for cooperation, May 2007

Press release 12 March 2007 SIN-NL starts Centre to report medical errors

Trust and professional autonomy of physicians.

Patient safety : terminology

Patient Safety and Patient Rights, J.Legemaate Comment P.Holland Dutch Med. Association Jan.07

The medical error:the physician, the medical records and the insurance-company: FRAUD!

Motives for litigation

Medical error: survey of role of medical and legal stakeholders:

The connection between the Oath of Hippocrates and hypocrisy

The silence

Every human being is responsible and accountable for his errors

Electronic medical records

Blamefree Reporting

Patient Safety

The exclusion from medical care and the wall of silence: a criminal offense?

The medical error:Image and Transgenerational consequences

Report First National Conference for Victims of Medical Errors April 23rd 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.

Open letter to Dr. Harry Molendijk, Chair Platform Patient Safety, 22nd Jan.2008

Sir,

On the 8th of January 2008 we had a meeting with you in your function of Chair of the Platform Patient Safety. You deliberately choose a very negative approach.
You repeated your anger that the undersigned addressed Minister Klink of Healthcare at the end of a congress the 12th of June 2007 and spoke to him about the refusal of honest information and remedial medical care to victims of medical errors.
I can now inform you that we had another meeting with Minister Klink on the 16th of January 2008 and spoke to him about recent developments.
You denied in our meeting of the 8th of January 2008 almost every about the serious situation of medical errors and the position of the victims.
You even denied the acknowledgment on the 7th of November 2007 by the Association of Medical Consultants, whom you represent, the Association of Hospitals and the Association of Nurses and Caregivers Netherlands, that physicians give virtually nil honest information nor adequate remedial medical care to victims of medical errors.
You indicated to have fear, due to you place on the black list. Is there a reason for this fear?
You demanded that we should rewrite our website completely. As you are aware we base our articles on the website only on facts.
This form of censorship is unheard of and unacceptable.
Moreover you showed and show a complete lack of respect and empathy for the unnecessary suffering of victims of medical errors, including the suffering of the undersigned, who is denied honest information and adequate remedial medical care for seven years, in spite of progressive disability caused by a medical error. This is humiliating and deeply offending.
On the 15th of February 2007 you told me during our meeting: Ms Hankes, you need medical care and I will arrange that. Until now, no medical care has been arranged.
You show behaviour, towards individual victims and victims in general, physicians unworthy,
Immedeate dismissal from your post as Chair is necessary.
You refuse to acknowledge our organisations as representatives of victims of medical errors, which the Associations of Medical Consultants, Hospitals and Nurses indeed did decide, as well as the Inspectorate of Health Care.
A very reliable force informed us that ZonMw judged the project Platform patient safety in a very negative way, which does not surprise us.
You were proud of the fact that you are already active in patient safety for six years. We refer you to the standard text of our correspondence, see our website www.sin-nl.org
Are these the results of your efforts: 8000 deaths and 8000 disabled per year due to medical errors in Holland?
The contact with you Mr Molendijk, neonatologist and coordinator patient safety Isala hospital Zwolle and as Mr Patient Safety, as you like to call your self. has for the time being come to an end, and may be forever.
The above is a summary of the meeting of the 8th of January 2008. We have thoroughly thought about this meeting and discussed it.
We regret that you made the choice to close the door to improvement of the position of victims of medical errors and of patient safety in general.
Please beware: your professional group is guilty for years of refusal of honest information and remedial medical care to victims of medical errors, as acknowledged on the 7th of November 2007.
�Hit and run� after a road accident leaving a victims without medical care is a criminal offence acccording to art. 7 of the Law of Traffic.
Refusal of medical care after a medical error is contrary to the Law on Agreement of Medical Treatment .As you persistently refuse to arrange medical care to victims of medical errors, we hold you liable for causing serious bodily harm and manslaughter to victims of medical errors, see the Penal Code.
We demand your dismissal. To achieve full transparency this letter will be published on the website and send as a press-release.
Sophie Hankes LL.M
Chair SIN-NL and the IEU-Alliance

Indications for medical errors, January 2008.

Medical errors :indications also based on the NIVEL report page 21 (Baker et al, 2004)

When you suspect that there might be a medical error, the following events can constitute clear indications:

1.rehospitalisation

2.prolongation of hospitalisation, transfer to another department

3.re-operation

4. admission to Intensive Care Unit

5. unexpected disability

6.unexpected death

7.no or unclear information leading to wall of silence

8.no or unclear remedial medical care, leading to abandonment of patient-victim

9.transfer to another hospital

10.infection and or sepsis

11. complications which are not the logic consequence of the illness of the patient or of the treatment.

12. unexpected dismissal from hospital to home

13. dissatisfaction about medical care in the medical records

14. complaints procedure (plans or actual) or litigation

15. all unexpected outcomes which have not been mentioned above.

These events can all make clear whether there has been a medical error.
Do ask for the medical and nursing records immediately and have a full and correct copy made. Never talk to a physician or a nurse alone by yourself, always arrange a member of the family or friend, to be present. You and they should be strong, dare to ask questions in a polite quiet way and be willing to make a report and sign it.
Do not accept unclear answers.
Physicians are obliged to inform you and should learn from their errors, in order to prevent further sorrow to other patients and families.

Dr Zylics killed my father.after medical error in the UMC Utrecht, 14 jan. 2008.

Herewith I announce that my father Lubertus Hankes was murdered by dr Z.Zylics on the 14th of January 2000, see the blacklist of SIN-NL.
Dr Zylics injected my father whom he had brought into a coma by administering morfine and dormicum without our information and consent and by withdrawing food and water.
Dr Zylics killed my father by palliative sedation, without our consent and killed him in front of my very own eyes. My father was injected and died half an hour later. He was finished off like a dog.
Dr Zylics filled in the deathcertificate, without informing me and without my consent.
In spite of my repeated requests he has refused to send me a copy.
There has been no legal investigation. Thus it is clear that Dr.Zylics wrote that my father died of a natural cause, which is NOT true.
This is a gross lie, as Dr Zylics killed my father.
July 1999 a surgeon of the University Medical Center Utrecht committed a serious medical error in the treatment of my father. They deliberately did not treat the consequence of the error, infection and let it develop to sepsis and a septic shock.
Only because I was alert and made a strong appeal to the responsibility of the physicians, they transferred him to the Intensive Care and he survived.
However when he got lunginfection, they withdraw treatment and he became a patient with serious heartproblems, which they also did not treat. Thus the Utrecht hospital has
speeded up his death, which has been ultimately realized by Dr. Zylics.
We did not go to court, although dr G.Blijham suggests this in Zorgvisie.
My father survived the medical mis-treatments for another 5,5 months and my parents were able to say goodbye to each other. I will never forget this moment.
The above mentioned medical mis-treatment are not registered in the medical records, see Inaugural Speech by Legemaate, 2006.
The role as patient-advocate for my father is the reason that the undersigned has been blacklisted by physicians and does not receive information nor remedial medical care for 7 years, in spite of progressive disability due to a serious medical error.
Further information available.

Sophie Hankes, LL.M. Chair SIN-NL and the IEU-Alliance

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!

Nivel report on medical errors: the victims and families of the deceased are NOT informed,sept.2007

On the 3rd of September an important public debate was held in Nijmegen, Netherlandson the Nivel report on medical errors in hospitals.
This report published april 2007 caused big headlines.
Holland was shocked by the high rate of victims of medical errors, which were in fact at least twice as high as the Health Inspectorate declared on the 8th of May 2007.
During the public debate in Nijmegen organised by the University Hospital Radboud more remarkable facts became known or were confirmed:
1.Medical records in hospitals are incomplete and inadequate. Pag 64 of the report states that 76% of the medical records were inadequate! This means that the conclusions of the report are unreliable as it was based on research of the medical records!
2.Cordula Wagner of the Nivel Institute confirmed explicitly that family members of the victims who deceased due to a medical error were not informed of the unnatural cause of death. The public was in shock.
It also means that the death certificates are quite likely to have incorrect information on a natural cause of death. Certainly death caused by a medical error is NOT a natural death.
Can this be qualified as fraud?
Are the 10.000 patients who were permanently damaged by medical errors informed and did they receive remedial medical care?
Quite likely this is not the case, which can be concluded from the following:
3. Dr Harry van Hulsteijn, deputy-chair of the Organisation of Medical Consultants and chair of the Commission Science, Education and Quality explicity told the public that physicians practically do not give aftercare to victims of medical errors. It means that they do not inform the patients that they were victims of a medical errors, nor did they give them remedial medical care.
So �.also the 10.000 victims of the Nivelreport who were permanently damaged did not receive aftercare.
Is this acceptable? No!
Physicians of Holland: you shouldbe honest and inform your victims adequately and give them proper remedial medical care. Moreover you should investigate your errors and learn from them.

Please start now:
Give proper aftercare to the victims of medical errors.
Arrange a parliamentary inquiry and truthcommissions.
Organise special policlinics for victims of medical errors
Work via the Tell and Repair proposal
Improve your medial records!

May the Nivel report bring improvement of healthcare for all victims of medical errors, and truthful information for the families of the deceased.

No debate but propaganda on Nivel report on medical errors, 3rd sept. 2007

On the 3rd of September 2007 a debate organised by the University Medical Center Radboud in Nijmegen will be held on the Nivel report: unintended damage in Dutch hospitals, published April 2007.
The debate was previously scheduled for the 25th of June 2007, but was cancelled.

The organisation of Medical Consultants, who ordered the report(!) and Cordula Wagner author refused to participate in the debate as SophieHankes Chair of SIN-NL and the IEU-Alliance would be a member of the panel of the 25th of June.
Thus the debate of the 3rd of September will be held without a representative of victims. At a debate both sides should be listened to. A debate without representatives of both sides is not a debate but propraganda.

THE NIVEL REPORT ITSELF IS INCORRECT.
Chief inspector Jan Vesseur of the Health Care Inspectorate clearly stated at the congress of the Dutch Association for Quality and Care 8th of May 2007 that the numbers of the report are incorrect and are at least twice as high.
The public version of the report mentions on page 13:�Finally the completeness and adequacy of the medical records in some hospitals was insufficient in order to formulate a proper judgment on the treatment.
A quote from journalist Willem Wansink in Elsevier 28th of April 2007 pag. 13:
�Unclear cases from the medical records are not counted. Medical records contain many errors: many times they are incomplete, as registerd by the Health Inspectorate recently�.
SIN-NL concludes on the basis of comparison of foreign research that the numbers of the Nivel report of appr. 2000 death, in stead of 8000 death, are much too low and unjustly create the impression that Dutch healthcare is twice as good as in other countries!
This is highly unlikely.
Again, the report is based on research of medical records and we are aware of the results of a report of February 2007 by the Health Inspectorate that medical records are often incomplete. Also Johan Legemaate, lawyer of the Royal Dutch Association of Physicians states in his inaugural speech 2006 that physicians generally are silent about their errors, also in their records.
76% of the medical records of the Nivel report was inadequate as written on page 64 of the report. So the conclusions of the report are incomplete and incorrect. New research is necessary.
Physicians should inform the victims of their medical errors openly and honestly
And report their errors to the Inspectorate of Health Care, in accordance with their legal obligations. Than appropriate research can be applied and prevention can be realized.
It is undemocratic to have a debate without the direct involved.
Exclusion of victims of medical errors is demagogic and undemocratic!.

Stop the wall of silence on victims of medical errors!
-see www.hetechtenieuws.org-
PS
An hour before the debate SIN-NL received a phonecall from the organisers and indeed given the opportunity to speak, as a member of the public, however.

Press release:Nivel/Emgo report more questions and call for cooperation, May 2007

Nivel/Emgo report April 2007 raises questions:
who is responsible for medical errors?
Minister Klink will present a plan to improve patient safety on the 12th of June 2007 at the Congress of the Inspectorate of Healthcare.
SIN-NL asks for the fact and calls for cooperation to improve the position of victims of medical errors and to improve patient safety.

The Nivel/Emgo report leads us to the following questions:
-why was the first public research on medical errors in hospitals in the Netherlands published only in 2007 and not years earlier?
-why did the researchers only analyse medical records and records by nurses?
-why appeared 76% of the medical records to be inadequate?
-why were patients not allowed to report their experiences on the medical errors?
-why has the position of victims of medical errors not been researched?

-why has �so far-no research been conducted on the situation of medical errors in primary care, nursing-homes, rehabilitation-centers and social security medicine?
-who is responsible for medical errors?
-what is the responsibility of the Association of Medical Consultants ?
-what is the responsibility of the Royal Society of Physicians KNMG?
-what is the responsibility of the Association of Nurses V&VN?
-what is the responsibility of the hospital associations NVZ and NFU?
-what is the responsibility of the Institute for Quality of the medical consultants, which exists already for 25 years?
-what is the role of the accreditation institute NIAZ, instituted by physicians?
-what is the role of the platform patient safety and its chair, also a physician?
-what is the role of the insurers for healthcare, with many physicians in top-positions?
-what is the role of the insurers for liability, as Medirisk which is owned by physicians/hospitals?
-what is the responsibility of the Inspectorate for Healthcare, run by physicians?
-why does the Inspectorater for Healthcare refuse to examine individual medical errors, in spite of the multitude of medical errors and victims?
-what is the responsibility of the government?
-are the above-mentioned co-responsible for avoidable damage caused by medical errors to victims and their surviving relatives?
-does patient safety only concern the future, as physicians prefer to define it, or does it also relate to the present and victims of medical errors in the past?
-IS SELFREGULATON BY PHYSICIANS EFFECTIVE?

-what is the role of the Dutch Patients Consumers Platform NPCF and especially Mrs van Bennekom? Was the NPCF active to improve the position of victims of medical errors?NO!
-what is the role of Nevemedis especially Martin de Leeuw, its chair? Has Nevemedis been active to improve the situation of victims of medical errors? NO!
-what is the true agenda of Mrs van Bennekom and of Martin de Leeuw?

-what is the responsibility of politicians and the media?

-who presents the facts in a clear way and arranges meetings with all parties involved?
-who participates in conferences?
-who proclaims that there is an emergency situation and pleads urgently to improve the situation of medical errors and its victims?
-who pleads to install a parliamentary inquiry and to install truthcommissions?
-who formulates proposals for solutions?
SIN-NL and the IEU-Alliance according to its social responsibility.
Minister Klink and all: let us cooperate to improve the quality of healthcare, let us work TOGETHER.

Press release 12 March 2007 SIN-NL starts Centre to report medical errors

Open letter to the Royal Dutch Medical Association, the Association of Medical Consultants, the Association of Hospitals, the Federation of Academic Hospitals, the Health Inspectorate, the Minister of Healthcare, insurers, politicians, media and all involved.
Each day appr. 20 persons die and appr. 20 persons become disabled in the Netherlands by medical errors at hospitalisations:
Appr. 300 victims per week
Appr.1300 victims per month
Appr.16.000 victims per year. (Elsevier weekly 10.3.2007)
These data are acknowledged. It is also acknowledged that appr. 50% of the errors can be avoided, see report 2004 by R.Willems, president-director Shell Netherlands. It is also acknowledged that many physicians do not inform their patients when a medical error occurred, inaugural speech Legemaate Amsterdam 2006. As a direct consequence physicians do not provide the victims of medical errors with adequate follow-up diagnostics nor with adequate remedial medical care. This has been acknowledged by Prof. G .van der Wal, Inspector-General of the Health Inspectorate in his speech on the 23rd of November 2006 at the opening of the congress of the 2nd pati�nt safety week in the Netherlands.
The quantity and consequences of medical errors are very worrisome for the victims and their families. 20 deaths per day and 20 persons who become disabled per day means an EMERGENCY situation.
It is remarkable that there is a lack of urgency to react adequately and respectfully to this emergency-situation.
Lives of human beings and the relief of suffering and pain are at stake. Beware: in case of medical errors the suffering is caused by a profession which strives to heal their fellow humans.
The medical profession and all involved should take their professional and ethical responsibilities concerning medical errrors NOW: physicians, hospitals, nurses, insurers, the Health Inspectorate and the Minister of Healthcare.
The Health Inspectorate does not examine complaints about individual medical errors, see its letter 26.2.2007. Please note: 16.000 victims per year and no research�.
SIN-NL takes it social responsibility and starts a Centre to report medical errors: www.meldpuntmedischefouten.nl
Report, report, report in order to achieve that medical errors can be researched, can be learnt from and can be avoided as much as possible, so finally��victims of medical errors will receive honest information and adequate remedical medical care.
We hope that we we will be able to solve the emergency- situation together. We are willing to co�perate.

Slachtoffers Iatrogene Nalatigheid-Nederland www.sin-nl.org
Suffers of Iatrogenic Neglect-Netherlands www.sin-nl.org

Trust and professional autonomy of physicians.

November 2006 the Royal Dutch Medical Association (KNMG) organised a symposium on Professional autonomy. SIN-NL was admitted as participant and was given a prominent role in the debat which was led by Professor Pauline Meurs.
The report Professional Quality was the base for the discussion.
After several speeches by physicians, discussions were organised in small groups, which was followed by plenary sessions. Many physicians argued that patients need to trust them: trust is the basis of the relationship between the physician and the patient. The Royal Dutch Medical Association also publishes this point of view.
SIN-NL however pointed out that quality and professional standards, evidence-based medicine is or should be the basis of the relationship between the physician and the patient.
Moreover SIN-NL argued that trust in the medical establishment did not lead to the highest quality of care. It is painful that systems to improve patient safety are so slowly developed, while 1 in 1000 hospitalisations results in death or disability due to medical errors.
A lawyer of the physicians organisation acknowledged that the self regulation fails.
Also physicians hardly report medical errors to the Dutch Health Inspectorate in spite of the legal obligation, art 4a Law of Quality.

Thorbecke ( a renowned statesman in the 19th century) said: freedom limited by the law.
SIN-NL pleaded and pleads for professional autonomy limited by quality and transparency. Transparency stands for openness and honesty.
Certainly we thanked the Royal Dutch Medical Association for starting the dialogue.
This congress also gave the opportunity to meet in person with Dr. G. van der Wal, Inspector General of the Health Inspectorate since October 1st 2006.

Maybe the question is justified whether the medical establishment does not trust its patients, especially in case of medical errors. Physicians -incorrectly- believe that all patients will immediately sue.
Experience in the USA shows that openness and honesty at medical errors leads to less claims and a better professional relationship between the physician and the patient, see
www.sorryworks.net, whereby there is respect for the autonomy of the patient.

Patient safety : terminology

�Patient safety�,� hot�, �adverse event�, �incident�, �system failure�.

Those who study the literature about patient safety frequently come across new words and concepts which are used in a special, uncommon way.
Suddenly the word �patient safety� appeared and it is called �hot�. The official Dutch dictionary van Dale defines �hot� as actual and in. It is quite remarkable to describe a large long existing social problem - medical errors which cause the death and disability of app. 40 persons a day in the Netherlands- as �hot�. Sometimes patient safety is considered a "hype"?!
Suppose you become disabled or a member of your family dies due to a medical error.
Surely you will be sad. Will you say: this has been caused by a �hot� problem or by a "hype"?
Who actually decided that patient safety applies only to �adverse events�- in normal Dutch medical errors- in the future? Why do physicians want to boycott the use of the word errors?
Why does patient safety not apply to the present victims, who were confronted with a lack of patient safety in the past?
Why do the responsible professionals decide the definitions of their dysfunctional behaviour?
Which value do physicians attach to the suffering of their victims?

International research* shows that 10% of hospitalisations results in medical errors, of which 1% results in death or disability: 1 in 1000 hospitalisations! This means medical errors are a structural problem. One can wonder whether it is justified to use the term �incident�.
The dictionary van Dale defines the word �incident� as disturbing event and �incidental� as less frequent and secondary. The word �incident� minimises the seriousness of the event in which e.g. a fellow human being died or became disabled.
The use of the word �system failure� is also doubtful. This word is used to place the responsibility at the system and denies the individual responsibility. A system is a set of procedures and individual activities. It is an abstract concept. Are physicians not human?
Individual activities, also by physicians are part of systems. Physicians have their own individual and personal responsibility.
The word �system failure� does not exist according to the Van Dale dictionary. Apparently it is the product of creative brains of the so-called patient safety experts.
�Patient safety experts� prefer to ask only the question: why and wish not to address individual responsibility. In case of a medical error it is however important to address all issues:
What happened? When did it happen? Why did it happen?
Who was involved ( passive)? Who was involved (active)?
What is the consequence (damage)? Can the damage be repaired, how, by whom and when?

November 23, 2006 the theme of the conference of the platform patient safety was:
Repair and tell! We support this completely.
Please use regular and understandable language. Physicians and hospitals: go ahead and provide genuine remedial medical care to the present victims of medical errors!
Medical errors are not �hot�. They are a long standing urgent problem.
Government, physicians, nurses and hospitals: address the problem of medical errors adequately and respectfully now!

Literature:
John Banja: Medical Errors and Medical Narcissm, USA 2005
Nancy Berlinger: After Harm: Medical error and the ethics of forgiveness, USA 2005
Van Dale Groot Woordenboek der Nederlandse Taal, NL (Dictionary Dutch Language).
*epidemiological survey of medical errors, see News

Patient Safety and Patient Rights, J.Legemaate Comment P.Holland Dutch Med. Association Jan.07

Free University Amsterdam, 10 May 2006

Please be aware that Prof. Legemaate is top legal consultant of the KNMG the Royal Dutch Medical Association. This means that he promotes the interests of the physicians. He is neither independent nor objective. His fairly positive approach does seem to open new possibilities.

Blame free reporting.
Prof. Legemaate strives for selfregulation by peers and for protection of the physicians who report medical errors, so called "incidents": he proposes voluntary , anonymous and non-central reporting. This means without legal obligations to report, without a system of sanctions and without indepent supervision. Also there is no system for individual and system analysis nor correction, nor the possibility to learn from mistakes.
As the Netherlands do know a legal obligation to report serious medical errors (art 4a Law on Quality) this raises the question whether voluntary reporting is legally valid.
Literature a.o. the 2004 Report by the Health Inspectorate make it clear that physicians underreport.
Physicians above and forall want to be protected against the consequences of their errors and they withdraw from their responsibility towards the victims of their medical errors.

SIN-NL sees personal responsibility as a moral obligation and strives for obeyance of statutory obligations to inform the patient and report the error.

It is very positive indeed that Prof. Legemaate has the opinion that physicians indeed have the legal obligation to inform the patient, also about medical errors. Hopefully he is able to convince the KNMG, Dutch physicians organisation, his employer. Sofar, the KNMG only focuses on the development of guidelines for the future.
At present victims of medical errors are generally not informed, as confirmed the inaugural speech of Prof.Legemaate! As a consequence patients do not receive adequate follow-up diagnostics nor remedial medical care as this would imply acknowledgment of the error and the damage, which might provoke litigation�..

This is the reason why physicians generally do not inform the patient. Research and experience in the USA show that if the caregivers inform the patients well and honestly, the patients generally do not sue. It is the denial and cover-up of medical errors by the physicians and the hospitals which enrages the patients and brings him eventually to sue.
Again, SIN-NL deems it legitimate to strive for statutory full and open disclosure according to the legal obligations. Moreover changes in Dutch insurance law in 2006 do not allow insurers to restrict physicians to inform and acknowledge medical errors. Legemaate should emphasize more clearly that physicans are ethically, legally and professionally obliged to inform their patients fully and correctly, Agreement Medical Treatment Law 1995.
Fortunately Legemaate is rather realistic in his approach that patients cannot be the guardians of their own patient safety, when there is no open and informative approach on the side of the physicians and hospitals.
He has probably never been a simple patient. Than he would know that an assertive question immediately provokes resistance at the physician or nurse and a very defensive attitude.

Legemaate notes justly that there are major problems with access and justice of the complaint-system for patients. The possibilities for individual justice certainly have to be improved.
SIN-NL awaits his proposals and hopes that Prof. Legemaate will urgently advise the Royal Dutch Pysicians Association KNMG to start the dialogue with SIN-NL on short term.
Not only words, but deeds as well!

In the mean time, SIN-NL met with Mr Legemaate, July 2006.
Also SIN-NL held a powerpoint presentation at a workshop at the congress Safe Incident Reporting, november 2006 organised by the Royal Dutch Medical Association. Unfortunately there has been no further contact with Mr Legemaate.

On the 11th of January SIN-NL had a meeting with the Chair of the Royal Dutch Medical Association Dr Peter Holland. Remarkably he denies the underreporting of medical errors, in two ways:
-he denies that physicians generally do not inform their patients/family about medical errors,
-he denies that physicians underreport medical errors to the Health Inspectorate.
Why does Peter Holland attach no value to the inaugural speech of the lawyer and professor of his organisation?
Why does Peter Holland attach no value to the report of the Health Inspectorate?
Why does the Royal Dutch Medical Association of which he is Chair, organise a congress about Safe Incident Reporting, November 2006?
Why is the first official speech of the new Inspector General of the Health Inspectorate Prof.G. van der Wal entitled:"Repair and Tell"?
Why is the theme of the second Week of Patient Safety November 2006:"Repair and Tell"?
Why does Peter Holland, physician and Chair of the Royal Dutch Medical Association deny these facts?
A thorough explanation on behalf of the Royal Dutch Medical Association is most necessary.
To be continued.

The medical error:the physician, the medical records and the insurance-company: FRAUD!

Prof Legemaate, lawyer of the Royal Dutch Medical Association has acknowledged in his inaugural speech, Free University Amsterdam(May 2006) that physicians in general do not inform their patients that a medical error has occurred. On of the main reasons is fear of litigation.

The physician thus denies the medical error, covers it up and does NOT register it in the medical record. This denial of the error and temporary or permanent damage for the patient, leads to incorrect medical records, to fraud. Even, in case of death after incorrect medical care, often a a natural cause of death is registered, although one might qualify the cause of death as manslaughter or murder if the patient was deliberately denied genuine remedial medical care and died. This has implications for the official registration of death, namely the registration of the cause of death is either inaccurate or incomplete.

This fraud extends to the medical and financial aspects as well as to the insurance-company.
As the patient does not receive genuine diagnostics nor genuine remedial medical care ( as this would inform the patient about the error), the inadequate diagnostics and �treatment� are registered in the medical records and nursing records. The physician furthermore sends his declaration to the insurance company and gets paid for� ghost� medical care!
The insurance can not examine the correctness of the of the physicians without the information of the patient. Thus the misleading physician and the misleading hospital receive payments for incorrect diagnostics and treatments and hospitalisations without any inspection.
Unfortunately medical advisors(physicians) of insurances attach more value to the importance of the professional allegiance than loyalty towards their employer.

Physicians, hospitals and insurance-companies work hand in hand to maintain the system of denial and cover-up of medical errors. Medical errors are not registered, nor analysed.
The medical profession chooses not to learn from their errors and there is no system of prevention. There is international consensus that 50% of medical errors are preventable.

Why do the authorities permit that patients become unnecessary victims of medical errors, to become disabled and even die? Why do the authorities permit the structural medical, administrative and financial fraud by the medical profession?

Motives for litigation

OPEN DISCLOSURE LEADS THE WAY TO RESTORATION OF THE RELATIONSHIP BETWEEN PHYSICIANS AND PATIENTS.

Patient�s motives for medico-legal action have been analysed and described into desires for four kinds of accountability*:

1. communication (explanation/apology/expression of responsibility)

2. restoration (financial compensation and appropriate remedial care)

3. sanction (professional discipline where appropriate) and

4. correction (action to protect future patients from harm).

Ad 1. Unfortunately it is a well known fact that physicians generally choose not to inform the patient about the occurring of a medical error nor the extent of the damage. This is quite distressing for the patient and his/her family, especially when serious harm occurred.

One of the major reactions of victims of medical error is the need for an explanation as well as an expression of responsibility and apology by the physician. This is one of the major reasons for litigation.

However,The �� Sorry Works� Coalition (USA) as well as the experiences of the VA Hospital in Lexington, Kentucky (USA) make clear, that litigation will not be pursued when the physician and hospital are open and honest abut the medical error and assume their responsibility.

Ad 2. For victims of medical error is it essential to receive appropriate remedial medical care after the medical error has occurred. Otherwise their health remains compromised which might mean progressive or permanent disability.

If the error is not acknowledged( due to fear of litigation), no remedial medical care is given and�the patient remains without this care, due to the professional allegiance.

It than seems that litigation is the only way to achieve the remedial medical care and financial compensation. However these goals will be extremely hard to achieve as medical experts will very reluctant to give objective reports, which might �accuse� a colleague of inappropriate professional care.

Ad 3.if the error could have been prevented, which is the case in approximately 50% of medical errors, the desire for sanction is not unreasonable. Sanction will be a sign of serious disciplinary action which shows that the physician is truly held responsible for his unnecessary error.

Ad 4. many patients and their family express the desire that future patients will be protected from the same medical error. This means that a system of analysis of individual and system accountability has to be carried out in order to realise a system of prevention. A necessary correct answer to medical errors will be prevention: Thus medical errors should be corrected. by prevention.

This will be of benefit to both the patient and the physician.

Experience has shown that litigation leads to further withdrawal of medical care to the patient and his/her family and can be therefore seen as dangerous.

The only people who benefit of litigation are the lawyers.( see article on this website:

Medical error:survey of the role of medical and legal stakeholders see Netherlands).

Litigation leads to further and unnecessary escalation and should thus be avoided.

Open and honest disclosure by physicians and hospitals is essential in order to restore confidence and the relationship between physicians and patients.

*M.Bismark and E.A.Dauer
Motivations for medico-legal actions: Lessons from New Zealand
Journal of Legal Medicine 2006, 27:55-70

Medical error: survey of role of medical and legal stakeholders:

Physicians/hospitals, lawyers and the patient/family

1.illness

2.consultation of physician/consultant :no treatment or treatment

3.result: o.k. or MEDICAL ERROR (10% of hospital admissions, 1% serious:1 in 1000)

4.physician:denial and cover-up of medical error due to FEAR of LITIGATION.
colleagues: denial and cover-up of medical error due to professional allegiance

RESULT: DENIAL AND COVER-UP OF TRUTH AND
PHYSICIANS EXCLUDE PATIENT/FAMILY FROM GENUINE MEDICAL CARE

5.in case patients decide to pursue justice via legal route:

6.lawyers invest hours and earn enormous salaries, paid by patient/family.

7.months/years pass before verdict. In most cases patient/family looses due to
lack of objective medical expertise- again medical professional allegiance.

RESULT: DOUBLE CLOSURE OF GATES TO GENUINE MEDICAL CARE, DUE TO BLACKLISTING OF PATIENTS/FAMILY WHO PURSUE LEGAL ROUTE.

Role of physicans/hospitals in case of medical error:
-denial and cover-up of the TRUTH,
-black-listing of patient/family and exclusion from genuine medical care
-professional allegiance: -upgrades position
- gives credit in case they make a medical error

Role of lawyers in case of medical error:
-hours/years of work: huge earnings. Litigation is financial advantageous.

Role of patient in case of medical error:
-seeks the TRUTH
-seeks genuine medical care
-looses health, looses financial savings, excluded from genuine medical care

In stead of the TRUTH : verdict for LIFE without fair trial, due professional allegiance by physicians and due to financial interests of lawyers. Is this justice?
CONCLUSION: LITIGATION IS DANGEROUS FOR PATIENT/FAMILY !

-Media, politicians and government are silent due to medical/legal network.

The connection between the Oath of Hippocrates and hypocrisy

The disfunctioning physician and his denial of medical errors are part of a system where openness and honesty are absent. Physicians will never make the errors of their colleagues public. The process of cover-up of medical errors is central in the preservation of the professional allegiance. A physician will never let his colleague down.
Therefore it is questionable whether second opinions are really independent and objective.
Often the victim does not get adequate diagnostics nor adequate treatment. This can have enormous consequences for various important aspect of life, ao work, social services, homecare.
Unfortunately it has become clear that the professional allegiance of physicians is an international phenomenon, in Europe and elsewhere in the world. Victims of medical errors have great difficulty in obtaining adequate healthcare abroad.

The silence

Based on the report To err is human : building a safer health system by the Institute of Medicine , Washington D.C. 1999, 3000 to 6000 persons die each year in the Netherlands as a result of medical errors. Many others become temporarily or permanently disabled.
According to calculations of the IEU-Alliance based on information of the National Patient Safety Agency UK 2005, see survey of medical errors: epidemiology (this website), each year appr. 8000 persons die in hospitals due to medical errors, and appr. 8000 persons are seriously injured. Precise data are not available due to the fact that medical errors are not reported, nor registered�.
Often the victim of a medical error is not informed about the occurrence of a medical error.
Notes in files are unclear or do not mention the medical error.
The responsible physician fears possible legal consequences and litigation and tries to prevent the legal procedure in many ways.
Nurses and other directly involved professionals choose often to be silent, out of solidarity or out of the professional allegiance to prevent possible sanctions.

Every human being is responsible and accountable for his errors

Every human being is responsible and accountable for his errors, including physicians, nurses and other direct involved.
According to SIN-NL there should be full openness and honesty about medical errors: physicians should report their mistakes, should learn from their errors and should engage in prevention of medical errors.
Moreover should physicians give victims of medical errors immediate adequate diagnostics and treatment. Unfortunately in case of medical errors genuine implementation of the Oath of Hippocrates is often not realized, leading unfortunately to hypocrisy.

Bibliography:
-Institute of Medicine(1999) To Err is Human; Building a Safer Health System. Washington D.C. National Academy Press

Electronic medical records

Physicians support the institution of an electronic database of all medical information of patients. Several questions arise:

who has the right to see the file?
who has the right to correct the file?
is there a guarantee of safety of information of the electronic database?

Only when patients have direct and unconditional entry to their own electronic record as well as direct and unconditional right to correct information of their electronic record, is the electronic database of medical information of patients acceptable.

Blamefree Reporting

Dr. Herre Kingma, former Inspector - General of Healthcare and Chief Medical Officer of the Netherlands has repeatedly defended blame free reporting of medical errors.
So has the University Medical Center Utrecht. Blame free means without accountability.
The supporters of this blame free reporting system expect that more physicians will be prepared to report medical errors. But why shouldn't a physician be accountable for his errors?
Prof. G. van der Wal Inspector-General of Healthcare and Chief Medical Officer since October 2006 also supports blame free reporting.
SIN-NL however gave a powerpoint presentation at the Conference on Blame Free Reporting, organised by the Dutch Medical Association on the 24th of November 2006 and has promoted the principles of openness and honesty as well as genuine remedial medical care and...focused on the fact that art 4a of the Law on Quality of Healthcare Institutions obliges physicians, nurses and others to report serious medical errors, where damage has been done to the patient, to the Health Inspectorate.
SIN-NL pleads to introduce a system of positive incentives at the reporting of medical errors, e.g. to honor reporting and to sanction not reporting.
We are delighted that Prof. van der Wal has adopted the goals of SIN-NL and the IEU-Alliance:
"to tell and repair "in case of medical errors, see his speech 23 rd November 2006 at the opening of the second Patient Safety Week with the same theme, in the Netherlands, see www.igz.nl.
We compliment him in all sincerety with his positive approach and invite the Health Inspectorate to strive for
adequate realisation of these important goals.

Patient Safety

Medical organizations such as the Association of Medical Consultants, hospitals ao the University Medical Center Utrecht , the government realize that changes in dealing with medical errors are necessary.
They develop various initiatives on the area of patient safety, conferences, projects at which is literally registered that the character and quantity of the damage for patients is unknown, special programs, 'Faster Recovery' www.snellerbeter.nl and a week for patient safety from November 23 - November 30 2005 by the platform patient safety www.platformpatientveiligheid.nl.
In London the United Kingdom government held a summit on patient safety. The European regional office of the World Health Organization organized a patient summit conference with international speakers focusing on patient safety www.regteam.com on November 30 2005.
It is remarkable that patients-victims of medical errors are hardly mentioned, and are not involved in discussions or decision-making to actually examine or improve patient safety.
The silence of patients-victims of medical errors is overwhelming.
However if the government, international institutions or professional medical organizations are seriously concerned to improve medical care, it is essential to involve and to listen to the patients-victims. The associations of patients-victims can serve as contact and intermediary:

Action on Medical Negligence Association (AMNA Northern Ireland)
Deutscher Patienten Schutz Bund e.V. (DPSB N. Germany)
BAG-Notgemeinschaft Medizinigeschaedigter Bayern ( Bavaria S. Germany)
Patient Focus (Ireland)
Patientforeningen Danmark
Sufferers of Iatrogenic Neglect (SIN Great Britain)
Slachtoffers Iatrogene Nalatigheid-Nederland (SIN - Netherlands)
united in the Iatrogenic Europe Unite Alliance.

The exclusion from medical care and the wall of silence: a criminal offense?

Physicians,
Nurses,
Hospitals, boards as well as commissions of complaints
Insurance companies of physicians and hospitals
Medical disciplinary boards
Health care inspection
Ministry of healtcare
Media
And the patient and his/her family

are aware and know that physicians generally do not acknowledge errors: errors are denied and covered up for fear of litigation *. As a consequence the physician abandons the patient and refuses genuine follow-up diagnostics and remedial medical care, even in the case of permanent of progressive damage to the health of the patient. Other physicans act according their professional allegiance and refuse medical care as well: the closing of the ranks occurs on a national and international level. This can eg mean that a patient suffers pain each day and becomes progressively disabled.

The �hit and run� phenomenon after a traffic accident is a criminal offense. This may lead to imprisonment. One can wonder whether the abandonment of the victim of a medical error by denying further medical care can be perceived as an analogy of the �hit and run� phenomenon and thus as a criminal offense. Reports by the World Health Organisation ** and the Council of Europe*** mention the possibility of medical criminal behaviour. One can even wonder whether the denial of medical care to seriously ill persons can be seen as maltreatment and torture. It is certain that the denial of access to medical care is a breach of art. 22 of the Constitution of the Netherlands as well as a breach of art 25 of the Universal Declaration of Human Rights United Nations 1948.

Sadly and remarkably the media and the authorities prefer to be silent. Whose interest is prevailing?

* J. Legemaate, patient safety and patient rights,
Inaugural speech Free University Amsterdam, may 2006
Bismark,M Paterson R. No fault compensation in New Zealand: harmonizing injury compensation, provider accountability and patient safety. Health Aff (Milwood)2006;25:278-83
Bismark,M Paterson R .�Doing the right thing� after an adverse event. N Z Med.J..2005 July 29; 118(1219):U1592
**WHO Europe Eight futures forum:on governance of Patient Safety, Erpendorf, Austria 2005
***Prevention of adverse events in health care, a system approach,
Council of Europe, Strasbourg 2005

The medical error:Image and Transgenerational consequences

Medical errors occur and from time to time the media lift a tip of the veil.
They usually describe individual cases and exceptionally dysfunctional departments of hospitals.

The media in general preserve a positive image of physicians, and nurses.
This is also supported by the many documentaries about eg emergency rooms and special attention for exceptional diseases, which are discovered and for which successful treatments are available.
Certainly physicians discuss the success stories and their excellent care to patients.
Few people know that there is often a special relationship between the producers or moderators of programs or organisations, with physician� s due to marriages.

However opinion-polls do show that the public is aware of the fact that physicians do make errors and are not always open and honest. The cover-up and closing of the ranks has in the mean time become not un to unfamiliar fact.

The professional organisations of hospitals, physicians, nurses try to give their image positive impulses by special projects eg �faster better�and are supported by the government.
The improvement of image is apparently not enough. The negative experiences of the public will be transmitted from generation to generation and will spread like oil, which is hard to remove.
These are the so-called transgenerational consequences of the years of denial and cover-up of medical errors by physicians and hospitals.
Actual improvement of the quality of healthcare is necessary, in order to repair the confidence in healthcare at the present and future generations.
Hospitals, physicians and nurses: beware!