Lisa Zenzen Baker, 1961-2003


Thursday, August 27, 2009

High-level cover up

State officials let hospitals
hide deadly medical errors

By David Baker
Posted Thursday August 27, 2009

In a story about a mid-air collision between a helicopter and a light plane in New York City, the Associated Press has revealed some details of the investigation into the cause of the crash. The AP obtained a copy of a transcript of a telephone conversation between an air traffic controller at Newark International Airport and a friend that took place just after the controller had cleared the light plane to take off and had handed control of it to a controller at another airport.

It appears that the Newark controller’s private conversation – during which he joked about “barbecuing a dead cat” – violated agency rules but did not play any part in the collision moments later in which nine people were killed.

The point though is that these details are already public, and that even if the AP had not obtained this transcript, the National Transportation Safety Board will carry out a detailed investigation and then write a report, which may identify the cause and will probably include recommendations investigators believe will make a similar accident less likely.

And that report will be made public.

Compare that with how the state Health Department handles the findings of its investigations of deaths and serious injuries in New York hospitals.

In most cases, they are kept secret, not only from family members who have been appointed as legal representatives of an estate but even from elected state officials.

That’s what happened in Lisa’s case. While a patient in Samaritan Hospital in Troy in 2003, Lisa lapsed into a coma after her glucose level – according to the hospital’s own records – had dropped to an almost non-existent 2 milligrams per deciliter of blood This happened less than six hours after she had had become hypoglycemic, during which, I found out later, nurses failed to follow the directions in the hospital’s own printed instructions for treating low blood sugar and, in doing so, ignored a doctor’s specific written order in Lisa’s chart to follow those printed instructions.

Then, after I learned from another doctor that records from that night had been removed from her chart, I made a request to the state Health Department for an investigation.

Six months later, Karen Rant, a ‘hospital nursing services consultant’ at the department’s office in Troy, called to tell me that an outside organization had decided that the care given to Lisa that night was appropriate and that as a result, no action would be taken.

Rant said department staff were stunned by the decision, and she certainly sounded shocked. During the months following Lisa’s collapse and death I had had numerous conversations with her and she had told me it seemed likely that the hospital’s staff had allowed a preventable injury to occur, by not following the hospital’s written protocol after the first episode of hypoglycemia, and possibly also by mistakenly giving Lisa quick-acting regular insulin instead of Lantus, which is released into the body over 24 hours.

Rant also told me that the report said some key documents were missing from Lisa’s medical records.

But the writer of a very brief “Summary of Professional Analysis of Care” I later obtained from the department dismissed any suggestion of improper care. The reviewer says the care was ‘appropriate’ and he or she twice insists that Lisa “… was being monitored closely”, even though the hospital’s records show that her blood glucose level was checked only once after the first hypoglycemia episode and that that was four hours before she was found almost dead and with a glucose reading of 2 mg/dL.

The reviewer says nothing about the nurses’ failure to obey a doctor’s direct written order, or their failure – again, documented in the hospital’s own records – to follow specific instructions in the hospital’s hypoglycemia protocol that the doctor had said in that written order was to be used if Lisa became hypoglycemic.

This ‘analysis’ was done by an organization called IPRO – which is partly funded by health care providers. The person who wrote it is almost anonymous, being identified only by a number: 350257. There is no indication that anyone at IPRO interviewed any of the people at the hospital who were on duty that night, which, Karen Rant had told me, staff from the Health Department's Troy office had done 13 days after Lisa's collapse.

So after seeing this summary, I asked the department for a copy of the full report.

They wouldn’t give it to me.

I filed a request for it under the state’s Freedom of Information law.

It was ignored.

I filed an appeal with the department’s main office in Albany.

It was denied.

So I wrote to then-Health Commissioner Antonia Novello.

In response, I received a letter from a Ruth Leslie of the Bureau of Hospital and Primary Care Services in Troy. In the letter, Leslie said that the department’s function in this case was to find out if there had been any violations of “the codes, rules and regulations of the State of New York.” and that because of the “medical complexity” of Lisa’s case, the regional office had sent the chart to IPRO for “an independent determination of whether the standard of care had been met.” This review, Leslie wrote, was in addition to, not in place of the department’s own assessment that all the rules and procedures had been followed by the hospital in its care of Lisa.

That, of course, was not what Karen Rant, in the same building, had told me the staff in Troy had concluded about Samaritan’s care.

But if the care documented in the hospital’s own records really was acceptable under the state’s rules, it seemed that those rules needed to be changed.

So I wrote to Richard Gottfried, who was then and still is chairman of the Assembly’s Health Committee, and to Kemp Hannon, who was chairman of the Senate Health Committee (a post he lost after the Democrats took control of the Senate in the 2008 election). I asked both of them if their committees would examine the circumstances surrounding Lisa’s death and determine, among other things, if ignoring a doctor’s direct order was allowed under the state’s rules and procedures, and if so, whether the chairmen thought that perhaps the rules should be changed.

It took several months to get any response from either of them. Hannon’s staff told me each time I called that someone would get back to me, but no one did. Then, when I pointed out to a staff member that she had been saying that for almost a year, Hannon told Fred Dicker – who had mentioned my attempts to get Hannon’s attention on his radio show – that I had been rude to his staff. Dicker evidently believed it and dropped the matter.

I never did hear from Hannon, which might be because while the Senate Health Committee’s chairman he had received almost a million dollars in campaign contributions, most of it from health care interests and some of it directly from Northeast Health inc., the company that operates Samaritan Hospital.

Gottfried, who also had being mentioned by Dicker, did eventually try to help. He wrote to Novello, asking for a copy of the IPRO report.

Novello refused to give it to him and Gottfried, while acknowledging that I might not find it satisfactory, told me he would take it no further.

Then, at Dicker’s suggestion and in a final attempt to get the report, I contacted then Senate Majority Leader Joseph Bruno’s office. During several conversations, Karen Crummy, an attorney on his staff, said she thought I ought be able to get a copy of the report and that she would contact the Health Department on my behalf.

Four months later my call to her was returned by a spokesman for the senator, who in an unfriendly tone told me that I was not going to get the report, or even hear any more about it from the senator’s office. And I never did.

It seems almost certain, given what I was told by the Health Department’s Karen Rant, and that no one will let me see it, that the IPRO report did in fact identify mistakes made by those nurses. If so, it probably would also have contained detailed recommendations for preventing the same thing happening again – even as the hospital, through its lawyers, denied any responsibility for Lisa’s death, flatly denied that key medical records ever existed and did everything possible to avoid being held accountable.

And why wouldn’t they? Everyone, it seems, has been putting a lot of effort – and money – into to keeping preventable deaths and injuries from public view. The providers, the politicians and, most disturbingly, the media, have all joined to hide the terrible truth. Meanwhile, we now learn that the number of avoidable deaths and injuries are not only much higher than had been acknowledged, but are increasing at an alarming rate.

Clearly, this secrecy, while benefiting those involved, has not encouraged providers to reduce errors. In fact, it probably had had the opposite effect, since providers are shielded from the enormous damage that would be done to them by bad publicly.

But it threatens the life of every resident of the state. They deserve to know the truth. That’s why I am working on a Web site to be launched soon that will make hundreds of past and pending claims against Capital Region providers visible for all to see.

As visible as that collision last month in the sky over the Hudson River in New York City.

Tuesday, August 25, 2009

Sorry DOES work

Hospital owns up to errors

But it's not in Troy......

Read the Wall Street Journal story HERE


Sunday, August 23, 2009

More hypocrisy

Another week and another Hearst newspaper
is calling for more "transparency" about medical errors

Meanwhile, there has been no response from the management of the Times Union to the open letter sent last week. No commitment to keep the topic of medical errors in the public eye. And once again, no denial of the allegation in the letter that for 10 years the paper has ignored virtually every medical malpractice lawsuit filed against providers in its circulation area - providers who have big advertising accounts with the paper.

With that in mind, read the latest Hearst newspaper opinion here

Sunday, August 16, 2009

The secret is out

Do as we say, not as we did

By David Baker
Sunday, August 16, 2009

An opinion piece that appears today in a newspaper in Texas offers some ideas for reducing the number of deaths and injuries in hospitals.

It suggests such things as including medical error as a contributing cause of death on death certificates – which doctors often refuse to do; increasing the use of electronic records; properly funding an existing state error reporting system; and asking lots of questions when you go to a hospital.

Then the newspaper has this suggestion if you are affected by a medical error:

“Go public with your story. Silent problems are problems that don’t get fixed, and this problem is killing far too many people.”

So which newspaper is it that is advising people to “go public” with medical errors?

It’s none other than the Houston Chronicle. The Chronicle is owned by the Hearst Corporation. Hearst also owns the Albany Times Union, which for the past 10 years has ignored virtually every one of dozens of medical malpractice lawsuits filed against providers in its circulation area.

Read the editorial here


Wednesday, August 12, 2009

Awaiting the next step


August 12, 2009

Dear Mr. Smith:

The publication in the Times Union this week of the investigative feature “Dead By Mistake” is very welcome. It already has started a renewed national discussion of patient safety, a topic that profoundly effects every person in this country.

And its publication is all the more surprising given that your paper – and, my research shows, others published by the Hearst Corporation – have for years ignored the issue.

You may recall that I wrote a detailed letter to you back in September 2004, in which I explained that I had become aware that since 1997 the Times Union had not reported a single medical malpractice lawsuit filed against medical providers in its circulation area – providers whose paid advertisements were appearing in large numbers in your paper. The suggestion was that you were refusing to print any bad news about entities that are a source of significant revenue.

I asked both you and then-publisher David P. White for a comment on this very serious allegation. I received no response.

Since August 2004 I have run a weblog on which, among many other items, I have published details of some of the many medical malpractice lawsuits your paper ignored.

By refusing to inform the public of these medical malpractice lawsuits, you joined medical providers, the legal profession and many politicians in a conspiracy; A conspiracy that benefited each participant but almost certainly allowed deaths and injuries that were avoidable, but which with immunity from publicity the medical providers had less incentive to prevent.

One of those deaths that might have been prevented but for your silence was that of someone you knew when she worked as a reporter at your former newspaper in Troy: My wife, Lisa Baker.

As I said in that 2004 letter, you allowed the providers to present themselves as competent, caring and honest, when as the “Dead By Mistake” project shows, in many cases they are anything but that.

For several months I have been planning to change that false perception. I have announced on my weblog that I will soon launch and aggressively promote a new web page that will list virtually every medical malpractice lawsuit filed against Capital Region providers since 1999, together with a weekly listing of new filings.

It would be hard to overstate the impact this will have on the staff and management of these medical facilities. But the end result should be a change in the way “bad outcomes” are handled. The days of a flat denial by medical providers as a standard response, no matter how obvious the liability, will be over. Finally, and very reluctantly, they will do the right thing.

Now, with the publication of a major project on the issue of patient safety, the Hearst Corporation has taken a step toward making that happen.

The question now is: Will it follow through?

Will you now report the filing of at least some of the lawsuits alleging medical malpractice by providers in your circulation area?

Will you describe for your readers how medical providers routinely put error victims through a second anguish by using an army of lawyers funded by huge insurance company resources to fight almost every claim – even in cases where the providers and their insurer’s experts have privately acknowledged that the providers were responsible for the harm?

That is the real test. You have eloquently described the problem. But that has been done before, with no more than a lot of talk – followed by even more avoidable deaths and injuries.

This time has to be different. Now, better late than never, will you be a part of a solution?

Very truly yours,

David Baker

Back to Capital District Health Claims page


Monday, August 10, 2009

Out in the open

Medical errors make
it to the front page

Posted August 10, 2009

In an astonishing change of policy, the Times Union and its parent company, the Hearst Corporation have gone from a decade of ignoring medical errors to launching an almost national effort to focus attention on the issue.

Involving reporters and editors from newspapers in seven cities and some of the company’s TV stations, the project, titled “Dead By Mistake,” examines both problems and possible solutions in patient safety.

One thing they might have changed is the project’s title. “Dead By Mistake, Concealed By Design” would have more accurately described the way most medical facilities have handled errors.

Also, the use of the word ‘mistake’ seems inappropriate when applied to overall policies. When you take a course of action knowing that people will be harmed by it, and you know that some of the harm could be avoided if you took a different course, that is a deliberate decision, not a ‘mistake.”

Nevertheless, this project will now bring a lot of attention to a subject that for too long too many vested interests have wanted to keep unchanged and unnoticed. There is still a long way to go but this is a very good first step.

Today an open letter is being prepared to be sent to TU editor Rex Smith. It will be posted here later this week.


Saturday, August 08, 2009

Hiding the facts

Shocking stories of
hospital cover-ups

Anyone who thinks that medical providers don't routinely conceal their mistakes need only read the series of articles that appeared at the end of July in the New York Daily News.

See all the stories in the three-day series here:



Friday, August 07, 2009