The experience had such a profound effect on both of them that they cofounded Medically Induced Trauma Support Services, a support group for patients, their families, and the healthcare professionals involved in adverse medical events. The correlation between disclosing errors and patients' decision not to sue has been borne out in some hospitals. The Veterans Affairs Medical Center in Lexington, Kentucky, for instance, adopted a policy of "extreme honesty" in 1987, and instead of their malpractice costs soaring, according to a study, the facility had one of the lowest payout rates compared to similar facilities. "Until we can establish openness and honesty in healthcare," says Van Pelt, "it will be hard to make progress. Without openness, you can't identify problems and fix them."

Although most doctors aren't willing to come clean, some are anxious to unload. When Dan Shapiro, PhD, a clinical psychologist at the University of Arizona College of Medicine, first invited physicians to participate in group seminars, he says, "I expected them to talk about patients who had taken advantage of them or made them angry by challenging their authority. But I was wrong. They came instead to talk about the medical mistakes that continued to haunt them."

Over the past four years, Shapiro has conducted seminars with more than 400 doctors, who, assured of anonymity, write heartfelt letters to patients they have wronged or harmed but, unlike Van Pelt, don't send them. "For many of these doctors, the pain and regret never goes away," says Shapiro. One physician, who had missed a cancerous tumor in the lung of a patient, wrote to the man's widow: "I'm so sorry we killed your husband. I want to cry with you, but I can't. But I'm crying in my soul, in a place where no one else can see. I was trained to do that, you know. Always, where no one else can see."

Remorse, however, does not constitute an apology; nor does an unsigned, unsent note. If the letter-writing exercise helps relieve some of the doctors' guilt, it does nothing for the patients they've hurt, or those who mourn the ones they've killed.

It's been five years since the Institute of Medicine brought the dark side of America's healthcare system into the spotlight. Since then no definitive data has come out to determine whether the number of medical errors has gone up or down. One study published in 2004 found an average of 195,000 hospital deaths a year resulting from medical errors, but many experts don't consider the findings scientific because it was done by a commercial company—Health Grades, which gives quality ratings for hospitals and nursing homes. An independent survey of more than 2,000 adults last year, however, did carry some weight. Conducted by the Harvard School of Public Health, the U.S. Agency for Healthcare Research and Quality, and the Henry J. Kaiser Family Foundation, this survey suggests that one out of three Americans is the victim of a medical error—personally or via a family member. For 8 percent of the population, the mistake proves fatal.

Still, the IOM report has stimulated some improvements in patient safety, and a few of them are coming from surprising sources. Last year UCSF Medical Center and a few other top teaching hospitals invited groups of commercial airline pilots to train doctors and nurses in teamwork and communication principles. "The pilots were flabbergasted by the lack of standardization within hospitals," notes UCSF's Wachter. "For example, they found that OR rooms are all set up differently, even in the same hospital. Pilots can walk into any of United's 737s, and they're all set up the same way—why would you want it otherwise?"

Increasingly, aviation parallels are serving as a model for patient safety for a simple reason. "If pilots make mistakes, they go down with the plane," Wachter points out. "In medicine we don't have that kind of personal incentive."

Nurses in many hospitals now routinely ask patients their first and last names before administering a medication or wheeling them into an OR. Doctors, for the most part, have stopped using confusing abbreviations on prescriptions, and the new so-called Universal Protocol means there are detailed guidelines for confirming patients' identities, clearly marking surgical sites, and verifying the procedures to be performed. Whether doctors will actually follow such recommendations, however, is another matter. "Many physicians don't like to be told what to do, and they perceive these requirements as slowing them down," Wall of Silence's Gibson points out. "They don't want to take the two minutes for pre-op verification. It's a change that is costless, and yet the value is priceless."

To counteract the fatigue factor, new regulations have reduced the number of hours residents can work each week from more than 100 to 80. But according to a recent study in The New England Journal of Medicine, critical care interns putting in more than 80 hours a week have double the rate of attention failures during night shifts than those working an average of 65 hours.

Gibson, who is also a senior program officer at the Robert Wood Johnson Foundation, worries that "no meaningful change will come until there is accountability in medicine and the culture of silence is dismantled."

Some victims aren't waiting around. After her son died, Helen Haskell channeled her grief into activism and introduced a bill now under review in South Carolina's legislature. Called the Lewis Blackman Hospital Patient Safety Act, the bill would require hospitals to give patients the telephone number of the attending physician and inform them when they're being treated by residents. "Any one of these provisions could have saved our boy's life," Haskell says.

In the end, the correction of many medical errors will come down to patients themselves. "Patient empowerment is key," says Robert Wachter. Fifteen-year-old Elizabeth Grimball knows this all too well. "I would tell people to trust their instincts," she says, "because you know your body better than anyone."

That means, if you have a hunch that something is wrong or not being addressed, speak up, get a second opinion, and if necessary, change doctors. "Sparing a doctor's feelings is not worth the price if that physician is wrong," adds Elizabeth's mother, Leila Grimball. "Medical negligence is painful for everyone, but it is the patient and his or her family who bear the brunt of the tragedy. And the heartache never totally goes away."


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