Before we turn our attention to this week's show, here's a quick mailbag of responses to last week's show on Vickie Kaminski, the new CEO of Eastern Health, one of Newfoundland's largest and most troubled health regions. Kaminski arrived on the heels of the Cameron Inquiry into errors in hormone receptor testing in that province. She has the oneous task of trying to fix long standing problems in the system while keeping up the morale of more than 13,000 employees, many of whom are planning to retire in the next few years.
It's only fitting that we begin with a comment from a Newfoundlander. Deborah Clarke of St. John's writes: "Thank you for the show on Eastern Health in NL. I felt for years there were many problems with our health care to the point when I needed surgery almost 15 years ago, I chose not to have it in my home province, even though I had a great doctor. I think your show is great. It is helping to educate people to take more control and responsibility over their own health care."
We also received praise for Vickie Kaminski. Here's what Carol Viau of North Vancouver had to say: "What an interesting, intelligent, well-spoken woman. Thanks for the interview. As a working woman, I am inspired by her example."
On the other hand, a number of you - especially those who like me work inside the hospital's sliding doors took serious issue with the way I went after those responsible for some of the errors we heard about on the show. Dr. Jason Doyle of Vernon, BC writes: "I found your "Hospital Fixer Show" to be a candid and enlightening glimpse into the realm of medical errors in Canada. However, when you were interviewing Vickie Kaminski, you inquired whether the nurse responsible for the medication error (carboplatin for Remicade) on Nancy Mojica-Fisher was disciplined. This is a fundamental problem with our attitude toward medical errors. True errors in medicine (or industry) should not be treated with punitive measures. This only encourages health care staff to cover up the errors. We must emulate the aviation industry (which has a much lower error rate than health care), which promotes a culture of candour and disclosure to ensure a root cause analysis can identify the problem(s) to reduce the risk of such an error recurring. Only in cases where malicious intent is evident should discipline or termination be undertaken."
Mark Edlund of London sent us this: "I listened with interest today the conversation with Dr. Goldman and the lady who suffered the medication administration incident in Newfoundland. Although tragic, I was disappointed in Dr. Goldman's question as to whether or not the nurse had been disciplined. I have worked in health care for 30 years as a pharmacist and have learned that discipline is not the proper response to such an error. The CEO's response as to the examination of the process causing the incident was much more appropriate. Errors such as this are devastating to all concerned. Compounding the issue by disciplining the "offender" only causes the incidents to be under reported. Proper reporting and response is essential to solve the problems behind such incidents."
Dr. John Beveridge of Calgary also took me to task for my approach to the medication mix-up that happened to Nancy Mojica-Fisher. He writes: "I listened to most of the program above and was very disappointed. In the past I have been impressed with the balanced candid presentation of various medical topics. I am a physician and Dr. Goldman must know that medical mistakes such as the medication mix-up (discussed on the show) are regrettable but unfortunately not that uncommon. To say this was "horrible" and ask if the person involved has been caught and punished is totally insensitive and unhelpful. Medicine has a long way to go to emulate the practices of airline control, but it is clear that blaming individuals for their "bad" care is not useful. Dangerous drugs are often packaged with similar labels as common ones, and there needs to be a series of cross checks starting from the pharmacy and ending up with verification with the patient. In the scenario outlined in the story, the nurses involved could not get her physician to respond to the incident and so they took it upon themselves to explain what happened to the patient as best they could. It is hard to believe that Dr. Goldman is a practicing physician as any doctor that points fingers at others, particularly nurses, without knowing the facts should be reprimanded. The least he could have done would be to talk to the nurse involved to find out what happened, as I suspect she is a good nurse that made a regrettable but honest mistake. I believe that the this type of journalism is harmful and creates distrust in a system that is run by imperfect human beings."
Thanks to all of you for letting us know where you think we've gone astray.