One Doctor's Crusade For Hospital Reform

Dr. Donald Berwick's Institute for Healthcare Improvement Hopes To Save Lives By Making Hospitals Safer

(CBS)  Dr. Donald Berwick, a Harvard-trained pediatrician, has dedicated his life to tracking a killer in a place that's supposed to make you well, CBS Evening News anchor Katie Couric reports.

"Hospitals are very dangerous places. I don't know how to explain this to the public in a way that doesn't create too much fear. But they need to be realistic, and the technologies that help you can also hurt you — and they do it every single day," Berwick says.

Berwick estimates that for every 100 patients admitted to hospitals, there are 40 to 50 incidents in which patients are harmed — ranging from bruises and bed sores to much more life-threatening situations.

"Between 44,000 and 98,000 Americans die in hospitals each year, killed by their care, not by their disease," Berwick says.

The doctor says he hear from family members all the time who say my husband or wife or sister died and it didn't have to be.

"My e-mail is full of the most poignant stories that are surfacing from families, loved ones, patients themselves, saying this happened to me, why did it happen? It didn't need to happen," Berwick says.

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Read How To Stay Safe In Hospitals

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Stories like 18-month-old Josie King who came to the hospital to be treated for burns and died from dehydration. And 27-year-old Joshua Nahum, who came in with broken bones and died from an infection.

"We need to build a hospital like you build an airplane, so that everything works right and there's a kind of automatic excellence in the system instead of relying on human effort," Berwick says.

Berwick runs the Institute for Healthcare Improvement, and two years ago, he launched the 100,000 Lives Campaign. That's the number of lives he hoped to save by getting hospitals to have standard operating procedures for the way they care for patients. This includes hooking up a ventilator properly to eliminate the risk of pneumonia and ensuring that a patient's medication is monitored from the ICU to the hospital room to home.

Berwick says even something as simple as uniform hand-washing requirements would cut hospital infections in half.

"We have a campaign team that makes field visits all the time," he says.

New York's Beth Israel Hospital is one of the more than 3,000 hospitals that have signed on to his campaign. Dr. Brian Koll is the hospital's director of infection control.

"The belief was, 'they're at risk and this was something to be expected,'" Koll says, explaining hospitals' attitudes prior to the campaign.

Catherine De Santis would once have been at risk for a life-threatening infection because of the tube she needs for feeding. But new procedures, championed by Berwick, have greatly reduced this danger.

"We standardized practices so that the line is placed in a sterile manner," Koll says. Following the guidelines has saved untold lives, he adds.

"I feel — even though I don't want to be in the hospital — a lot more comfortable bring here," De Santis says.

The campaign does more than save lives — it saves hospitals money.

"A lot of people ask 'how can you afford to improve?' The answer is, 'you can't afford not to,'" Berwick notes.

Now his organization is making even more recommendations to ensure hospitals are safe.

"If I'm not fighting uphill battles against unreliability and dropped balls and things that go wrong, well, now I have time to sit with you and hold your hand and look at your face and answer your questions and do all the other things that only a caring, committed human being can do," Berwick says.

He's emotional about it because, he says, "it's in reach. It's just a matter of will and leadership."

The will to adopt small, simple steps that could greatly reduce complications and ensure that many more people live to leave the hospital.

Ms Couric during your spot I couldn't help notice that during all the comment about handwashing not one of you, Katy, Dr Koll, or Dr Berwick washed their hands as each one of you touched the patient! The at risk person was exposed to each of you and everything you touched.
I can readily understand Dr Berwick being emotional. He is so grateful for CBS' and Ms Couric's promotion of another potential regulatory agency and all the revenue that entails! "Exaggerate, shock, then announce your product!"
Self promotion at expense of the at "risk population" freely sponsored by a major news network erodes the credibility of that network.
Dr's Koll and Berwick need to seek time on an info-mercial network.
The viewers are not all gullible minimally educated lunatics. We do expect better from CBS.
Sadly
Ralph Franklin, R.N.

[rnhopkins4]

Katie,
This topic is particularly interesting as I am a nurse and am in grad school for nurse anesthesia. It is terrifying when learning about all of the errors that happen in the hospitals. I have worked at two of the nations top hospitals (Johns Hopkins and Mass General)and sometimes errors just happen. The secret is preventing these errors by changing the system is which they are carried out. I wanted to add a nursing perspective to the story...after all nurses carry out most of the orders and many errors don't happen because nurses are well educated and catch them before they occur. I don't know how many times I have questioned a physician about the meds he or she prescribes or have gently reminded them that they are doing something wrong. With this being said; I am sure you are well aware of the nursing shortage. This translates to greater nurse to patient ratios and a greater chance of errors and nosocomial complications. For example to prevent skin breakdown and bed sores a patient must be turned every 2 hours. With a heavy assignment it sometimes is difficult to accomplish this. In addition there is never enough staff to help you turn your 300 pound patient. There are lots of interventions that can be carried out to further decrease errors. Never forget the importance of a nurse and the important role they play in health care delivery. I always said that it is the nurse who is going to save your life; not the physician.
Andy RN

[stretchbarry]

Dr Berwick had me in tears as I watched is interview. My sister and I have a story to tell that is too long for writing all the details. I don't know if there is a way of getting in touch with Dr. Berwick , but I would appreciate an e-mail address if at all possible. We have been looking for an answer and I believe this man is what we are looking for.Please allow us to share our tragic story with Dr. Berwick by sending me his address. We will be waiting for a response.
Sincerely,
Trina Barry
2006 Oak Place
Round Rock, Texas 78681

512-246-7198
512-461-1197 cell

[docrob4]

I applaude Dr. Berwick's efforts in reducing hospital deaths due to gross incompetence by medical staff [I've lost family & friends from this]... I intend to pursue this issue and lend my support - it's important ...

- Dr. G. Robert Wilson [BA, MA, Ed.D, Ph.D.]

[tricha2]

A very interesting article and very true. My brother, Lawrence Carter, was killed in a hospital in New Orleans years ago. The doctor told me that, "the nurse left him off the machine too long." I was overcome with grief and could not handle it emotionally, so nothing was ever done about it. My mom was also very sick and elderly.

Working and constantly running down to New Orleans by plane, train, and even buses to see about them was too much for me. They would not relocate to Maryland as I pleaded with them.

I wish I had known what to do and was able to think clearly at the time. The nurse should be charged with murder. I am sure that by now they have destroyed the records to cover their tracks.

Also, I have been personally been disfigured by a "butcher", Dr. Robert Dennise, at Howard University Hospital. His license should be revoked so that can never butcher/disfigure and cause constant permanent physical and mental pain to other patients.

[mousew1]

There is something that seems so simple (to me any way) to help keep hospital patients safer/healthier yet I have never seen it done and that has always puzzled me:
Handwashing by patients before eating meals is neglected on a regular basis, especially for pateints who are bed-ridden. Caregivers wash their hands, visitors wash their hands (some of the time), there is anti-baterial gel available at every turn; yet patients aren't even give a wet wipe on their food tray to clean their hands before they eat. I have had family and friends at many of the major Boston hospitals and it seems to be the same everywhere. I would think this would be a simple, inexpensive way to help keep patients healthier during their hospital stay.
M. Wells
Massachusetts

[jalennart]

Katie,
I was very interested in Dr. Berwick's story. I was released from the hospital last week after a nurse overdosed me on my long-acting insulin. She claimed she couldn't find the "right" syringe. It took 2 days for them to get my blood sugar under control. My sugars ranged from 52-63 for 2 days. They were giving me injections of a thick sugar substance into my IV many times throughout the 2 days. I was on a hourly blood sugar check for more almost 48 hours straight. So sometimes it is the Nurse who makes the mistakes that can be fatal. I wish Dr. Berwick continued success with his crusade.
Sincerely,
Jackie Lennartson
2168 128th Lane NW
Minneapolis, MN. 55448
[phone]

[rray52]

Bravo Zulu Doctor

[scholtes1]

We were touched by the story about Dr. Berwick's work. Thank you to CBS and to Dr. Berwick's heroic and important work for healthcare improvement in our hospitals. Thank you for letting the public know about how our health care institutions can improve.
A great story about great work by a great man.
BRAVO to all of you.

Peter and Peg Scholtes

[durant8]

I would like to have a list of the 3000 hospitals that have signed on for this campaign.

[bkollmd]

I just wanted to let Mr. Franklin know that Ms. Couric, Dr. Berwick and I all washed our hands before touching the patient and afterwards. We used the alcohol based hand gels that are available throughout the Medical Center. Unfortunately, that was not shown during the broadcast. The Medical Center has conducted numerous campaigns for hand washing/hand hygiene to assure 100% compliance. As part of the campaign many of us wear buttons on our lab coats asking patients to ask us whether or not we washed our hands. Nurses are empowered to enforce appropriate hand hygiene practices. This is something that we take very seriously and it is a team effort.
Sincerely,
Brian Koll, MD

[edprichard]

Bravo Dr Berwick! (And CBS) All hospital personnel: administrations, medical, nursing and ancillary staff should be rewarded for detecting and fixing problems, not ostracized. And every patient needs anadvocate.
My wife recently had a spinal infection from Staph, contracted thru surgery and then misdiagnosed for a month because physicians failed to put aside their egos and communicate well. She was eventually overdosed with pain meds, which were not monitored by nursing according to policy. Her breathing slowed, then stopped. I called the nurse and she wouldn't do anything without the doctor's permission (at 3 am). Being a lab person, Navy corpsman and an EMT, I told her to follow the universal protocol and discontinue the drugs and administer Narcan to counteract their effect. She wouldn't because she said she was intimidated by the doctor. She finally relented, providing I agreed to be a witness for her.
Later that day the (incompetent) doctor restarted the pain meds and subsequently my wife suffered respiratory arrest and was placed on a respirator for 15 days in ICU...where a competent surgeon reread the spinal images and performed emergency surgery. Few ever question the interpretations of the radiologists and pathologists. They send written reports that are accepted without sufficient critical analysis and rarely face a "real" patient.
The state governments we rely on do little or nothing to assure professional performance.

E Prichard, Kitsap Co, WA

[spenny4242]

Your news piece about the safety in hospitals hit home for me. In 1994 I had surgery (hysty) and after I returned home had to be treated for a staph infection that I contracted in the IV site. That took several trips to the doctor's office and additional treatments to get rid of it. It was in my left hand and going up my arm to my heart. In 2003 I had brain surgery for an
aneurysm. The surgery was the radical choice and done on a monday. The nurse that was on the day shift that monday and the following wednesday would not give me the morphine that was ordered for pain. I ended up with no medication for approximately 8 hours per day. I registered many complaints with my doctor's knowledge and was only told that the hopital would check into the matter but I would never know the outcome. Nor did I get any thing the even resembled an "We are sorry."

[michellem99-2009]

I lost family members due this very thing. I almost lost what little sight I have due to this. I am thankful a Dr. was able to save my only low vision eye after one of his peers messed up. I was so scared. I know hospitals are dirty,nasty places.They truly NEED to clean up and do a better job at it. There is no ifs,ands or buts in this issue. I am grateful that somebody has brought this into the open. Now don't think about it-Do it. The hospitals need to be safe and clean. They need to step up to plate and do the right thing. I feel that the Drs and others who work in the hospitals have to do better as this is an outcry for health and safety. I don't fully trust the hospitals. I do have my reasons. I want to live not die in a nasty place. Katie,dear as you tell the news you do bring to light things that need to be said. I keep my hands clean as I use them alot to see with. Best wishes to the Dr. on his mission clean up the hospital care systems. But will the health care systems learn anything from this very timely story or carry on as they always have. It is a wake up call.There is no room for errors. They need know where things are that they use and not be dumb. After all the sick person's needs and welfare comes first and the right care given at all times. Wash your hands. Hospitals are dirtier than the home. Are they too lazy to clean the hospitals or is greed of money the reason or both.

[gmamagonz]

The rates of deaths are such a wide range I am curious as to his source of data. I am nurse working in a hospital in a metropolitan area with nationally recognitized medical center. It does take all services medical, nursing, and ancillary staff to turn things around. What most people don't know is that most quality improvement systems are developed and initiated by the nursing departments. Physicians can be very resistant to change. Mandates to alieviate patient's pain, and reconciling medications are initiated by Joint Commission Review Boards. Sometimes however specialty area issues are not addressed. Labor and Delivery is one of them.
The focus such as procedure site seems rediculous from that aspect. There are only two sites, one the baby chooses and one the physician chooses. Mandating care takes away critical thinking skills and staffing shortages takes away consistency at the bedside.

[klosinski1]

There is a great book that I just read called "Nursing against the odds". It can really open your eyes to some of the problems going on behind the scenes in the healthcare industry.

[anopinion1]

One thing, above many other, medical classes engrain into you is to wash your hands before every procedure then put on gloves do what it is you need to do, take off the gloves and wash your hands again.
If their is still a problem today with hospital employes not washing their hands its really pretty sad and careless.

[drdenisee]

It's sad that no one comments on the good things that physicians and other medical staff do with healthcare reimbursement dropping and medical liability increasing. When a national news organization covers an issue in this way with no counter coverage about the good things, people continue to be litigious without recognition for fact or reason. The baby that died from dehydration due to burns? Dehydration is a known risk due to burns....Get ALL the facts and get them all straight before you put out a story like this.

[cat012]

would like to know how to get in touch with dr.donald berwick,things here at martinsville hospital are pretty bad also,i almost died this past wednesday jan 31,due to lack of communication which resulted in giving me meds to fast in iv,i went in with pneumonia and asthma wrong meds also,my doctor came in next morning and said i didnt realize how close i had been to death,if i had been a little older my would have had heart failure,and kidneys with have shut down,my doctor is highly upset as i am,she wants me to file a paper to the administration board,but i dont really think that will go along way,please pass this note on to dr.donald berwick,i would greatly appreciate it,there is more to this story,sincerely,cat012

[jonespbipap]

Dr.Berwick and the IHI are right! I am fortunate to work in a hospital that embraces these values of reform. We are also fortunate to have a high level of collabortion between nurses, doctors and others. We recognize it is not about 'us' or "OUR" needs; it's about the patients' safety.
Thanks CBS for airing the story.
P.C.Jones
Maine Medical Center
Portland, Maine

[klorraine-2009]

Part-1

I seen on your show yesterday about Dr. Donald Berwick is helping patients over malpractice issues.

I had encountered a medical malpractice experience myself. And had been trying to get changes made in the medical field. I was told when I had tried to get a petition going that this issue had been resolved. And I happen to be told that there were a law passed this year. I seriously haven't seen any changes made. During my experience a physician without knowledge I was carrying twins and end up killing my other
daughter by using the instrument vacuum
extraction on one of my daughters. I was ignored
by the nurses when I happened to go back in
labor. The doctor had already left. When my
other daughter happened to come out she was
covered with her own placenta. My daughter was
carried out by a dust pan (broom) by a nurse.
And she had stated she was a blood clot. Well my
records weren't sent to me at my request and
today has disappered. Now there are new workers there at this same place. And they have tried by the request of chickasaw nation to help me. These hospitals/clinics have control over the evidences the records. And can get by
with murder. I left that place sick along with
my other daughter that had survived.

[klorraine-2009]

Part-2

And since I have a rare bloodtype I almost lost my other daughter because of what had happened in the pregnancy before. And this same place told my hometown physician to tell me to go home and propp my feet. This doctor had became upset
because the situation was bad. I have heard of
so many malpractice incidences. Gauze left
inside of a woman. Later develope cancer and she died. A wrong artery cut on my cousin she almost bled to death. And a papsmear done on another one of my cousins when she was pregnant. She lost her baby. There are so many cases. My question to you. Has there been any law changed over medical malpractice? And what was passed and if you know when? I have been in contact with senators and congressmens and so on. When I lost my baby during the pregnancy I did get to hear both heartbeats but there were no clearification the second time around so the doctor didn't record this thinking this was a mistake. And in the last trimester I was on the verge of loosing my other baby (twin) to where the part of placenta she was on fell to the bottom of my uterus. I could feel the pressure on my pelvis. But I know there was that great chance she was alive until the time for delivery.

[klorraine-2009]

Part-3

I found out today that vacuum extractions can and has been dangerous to the unborn. And the pressure of this procedure I feel is what killed my daughter. If you can help me with whatever information I'd appreciate this so much. And I do feel greatful that Dr. Donald Berwick is helping ones like me. I know there's some good doctors left. And I was told by one of the senators that situations like this can cause problems for good doctors. But like I tried to explain this isn't the patients faught. We are vitims moreso by these bad choices these bad doctors make

Thank you,

Karen Johnson

[klorraine-2009]

The remaining ending to my statement:

I lost my daughter 12-30-1988


There was a statement made when I tried back in the 90's to collecting my records. They messed up by stating I never experienced any blood clots during my pregnancy's or delivery. And they base statue of limitation on murder in the medical field. I happened to develope PTD over what happened. I had amnesia for a period of time. And when it all came back to me was like reliving the whole ordeal.

Karen Johnson

[amtunvis]

The irony of the timing of this story is that, even while the amount of death and injury from errors in hospitals and by doctors is on the rise, the insurance companies are still going from state to state attempting to limit the rights of the injured victims and the rights of the surviviors of the dead victims. They do it all with propaganda that tries to make the consumer believe that healthcare costs are rising, and doctors are leaving practice because of a "lawsuit crisis." The fact of the matter is taht the only crisis is one of healthcare safety, as succinctincly pointed out by this story. Michael Townes Watson, author of i America's Tunnel Vision--How Insurance Companies' Propaganda Is Corrupting Medicine and Law. /i www.StopMedicalError.com

[rinks4]

Nurse Franklin - I am appalled by your comments
I am a nurse and Risk Manager of a major medical center and I see first hand what happens. We all need to heighten awareness about medical errors, we need to educate our patients, we need to mentor our young new nurses. Harm occurs to only one patient at a time; not whole groups of patients making the incident less visible. What's the exaggeration? If anything understated. Shock - yes for the healthy person who doesn't have much interaction with the medical community. Our focus should be on system safety, not individual blame and errors do occur. I would work with Dr. Berwick in a minute to promote a culture of patient safety. You need to read the Institute of Medicine's landmark report To Err is Human: Building a Safer Health System. And how do you know they didn't wash their hands or maybe they used the hand gel! I have much respect for Katie Couric - she is a patient advocate in her own way...how many people do you know now go for colonscopy's because of Katie....I know many - Katie - you go girl....and Nurse Franklin remember we are all part of the patient saftey team and when you go to work make sure YOU wash your hands and fill out that incident report when an error occurs and send it to your Risk Manager!
And when you think there is somone more important than the patient...think again

[hospitalrn1]

As a nurse in a hospital, I see a general lack of infection control in the hospital. This includes staff being careless with cleaning IV sites before injecting into them, dropping IV tubing on the bed without capping it and reconnecting it to the patient. I see multiple patients who aren't told by their doctors that they are diabetic or have a diagnosis that they know nothing about. It's hard for a patient to treat an illness they know nothing about. So many protocols not being followed because the staff just doesn't have time. Nurse's are not only taking a group of 6 - 8 patients, but each patient has a doctor (or multiple doctors), multiple family members calling, an average of 100 meds to pass to 6 - 8 patients every morning, different departments calling, and massive amounts of paperwork to document in 8 hours. That leaves an hour per patient in one day, before you get report from the prior shift, pull all of your 100 meds to pass from a machine, check the lab work and so on. One nurse counted the number of interruptions she had in her shift... after 4 hours of working, she gave up counting. She had over a 115 interruptions in 4 hours. How do you deliver healthcare that is safe when there is no time to provide the care?

[lbartlett7]

My Dad died 2 days after surgery in Searcy, Arkansas on 12/29/07...He went in to have a small cancer removed off of his kidney. This cancer was contained. When the doctors got in there they ended up removing his entire kidney.....He was 77 years old.
I think some Doctos are too surgery happy these days....My Dad was strong as an ox, but something went terribly wrong in surgery and we lost him two days later. I do not feel that the hospital took care of him at all....Lisa Bartlett, Jacksonville Arkansas

[Sue Gullo]

To KLorraine, losing an infant or pregnancy at any age is very traumatic and a terrible loss. There are organizations that can help you in resolving this traumatic experience. As a former Director of an OB Unit, our patients found this group very helpful. SHARE- Pregnancy and Infant Loss Support Group is a national organization and their url is http://www.nationalshareoffice.com/

Also check with your local hospital to see if they support these meetings on site.