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Thursday, July 2, 2009

You have to ask patients: Testimony of the Consumer Health Quality Council

This was the testimony I delivered before the Joint Committee on Public Health of the Massachusetts State Legislature on June 23:

Thank you for the opportunity to provide testimony on House Bill 2084 and Senate Bill 909, An Act to Reduce Medication Errors in the Commonwealth.

I'm Ken Farbstein, the President of Health Care for All's Consumer Health Quality Council. Nineteen years ago, my wife was about to give birth to my son, in one of the Harvard teaching hospitals. Way up in the same building, we heard that doctors were treating one of the princesses of Saudi Arabia, who was there because the hospital had such a great worldwide reputation. But our team of doctors made a really basic misdiagnosis. My wife got the wrong drug for 12 hours, and she didn't get any pain medication for the first 12 hours she was in labor. We never formally reported either one of these two medication errors – our son was in the NICU for three weeks, so we couldn't think about anything else. I'm bringing up this story now to make a simple point: The vast majority of medication errors are never formally reported within the hospital. To find out about them, you have to ask patients.

Other Consumer Council members have also experienced medication errors that were never reported as such. One member was given a medication by a neurosurgeon that brought on a seizure, even through she told the doctor that she had experienced seizures in the past and knew this medicine was related to their occurrence. Another Council member was never given pain medicine following a surgical procedure, even though she requested it and her doctor had approved its use. A third Council member contracted an intestinal infection as a result of being given multiple antibiotics while hospitalized. To learn about many medication errors, you have to ask patients, and the expert panel required in this bill can do that.

Back in 1999, there was tremendous shock when we learned from an IOM study that 98,000 people were found to be dying of medical errors every year (14,000 of them from medication errors). Then seven years later, we were shocked, again, to learn from the IOM that 1.5 million people a year suffer injuries from preventable drug errors.

We need to fix this. We need an independent panel of experts – which this bill requires - to review what has been learned, what works, and to make formal recommendations within a year, and then embed them in law and ensure that there are sufficient reporting and oversight mechanisms to stop the harm to people and the waste of money.

Thanks for your consideration.

Advice: Together with your supporters, tell your legislators what you care about.

Read our testimony on another bill, or see the short video of the testimony of Health Care for All President Amy Whitcomb Slemmer, and Council members Ginny Harvey, Lucilia Prates, and me.

Thanks to Deb Wachenheim for her legwork in organizing our panel for the hearings.

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