Patient Safety Quiz: The Power of Telling our Stories

Q1.Which headline was on the front page of the New York Times this week:

A) Man Bites Dog
B) Israeli and Hamas Leaders Mark Broad Peace Pact with Joyful Group Hug
C) Large Hospital System Fires CEO over Patient Safety Problems


Yes, it was a toughie, but if you guessed C, you’re right. Bob Woodruff broadcast his story, and stories of other American men serving in Iraq, about brain injuries and the frequently inadequate treatment for them. Yesterday’s NY Times headline read, “Army Secretary Ousted in Furor on Hospital Care,” and the story noted it was “the second change of command in two days.”


Q2. Which national hospital system has both a unique and outstanding electronic medical record that integrates patients’ histories over inpatient and outpatient visits, AND a computerized physician order entry system with a dazzling set of alerts to protect patients against medication errors?

A: The Veterans Health Administration


Q3.In 1982, New York Yankees owner George Steinbrenner fired two managers, four pitching coaches, and two hitting instructors. Did it help?

A: No. They lost more games than they won.


Q4. Which hospital has made tremendous progress in patient safety since firing their CEO in the wake of the widely told story of a medication error that led a journalist’s death? Hint: The hospital’s exemplary patient advisory council is a focus of pending Massachusetts legislation.

A: Dana Farber Cancer Institute. Only time will tell whether these firings have effects more like those of Steinbrenner or the Dana Farber’s Board.


Woodruff's public airing of these men's powerful stories may make it possible to speed the return to good health of thousands of wounded veterans.

Advice: Your stories are powerful! Share them with us, and share our stories widely with your family, friends, and colleagues.

Read another story about a veteran’s care.

Not only to linebackers: Undiagnosed brain injuries

Last night, ABC broadcast the moving story of journalist Bob Woodruff’s miraculous recovery from a severe head injury from an improvised explosive device in Iraq. Woodruff’s program warned that many soldiers have invisible, undiagnosed head injuries due to the concussions they suffer in explosions.

This tragic war is disturbing enough, as are the heart-breaking images of our wounded soldiers. Adding insult to the injury is the frequent failure to diagnose their head injuries, and once diagnosed, the failure to provide adequate treatment.

Mr. Woodruff illustrates quite graphically that some veterans are sent home to recuperate in smaller cities that do not have veterans’ hospitals equipped to handle the growing number of those returning with severe traumatic injuries. He interviews a young soldier who is slowly but steadily recovering at a state-of-the-art veterans’ polytrauma rehabilitation center in Tampa, Fla., then checks in on him weeks later in his hometown in Texas, where he has noticeably regressed.

Others are not even diagnosed. One solider in the story mentioned the frequent memory lapses he attributes to undiagnosed head injuries in Iraq.
Researchers screening returning soldiers and Marines at four military bases found that about 20% of troops in front-line infantry units had suffered such injuries.

"This blast group is going to be potentially huge," says Angela Drake, a neuropsychologist with the Defense and Veterans Brain Injury Center, a research arm of the Department of Veterans Affairs and the Pentagon. "We're looking at thousands of potential patients." Military doctors describe brain injuries as a signature wound of these wars. That's because advances in body armor save soldiers who might have died in previous conflicts, but blast waves from roadside bombs can cause brain damage. U.S. troops in Iraq are exposed to hundreds of bombings each month. "We've seen patients who have had three deployments and have had some (head) injury on every single one," Drake says.

The damage from multiple concussions can be irreversible. "Repeated concussions can be quite serious and even lethal," says Air Force Maj. Gerald Grant, a neurosurgeon who treated troops in Iraq.

Eight months ago, Pentagon health official Michael Kilpatrick said “in a few months,” combat medics could start using a simple mental exam to show evidence of concussions. The time is now.

Recent news reports describe the many concussions suffered by Tedy Johnson, a former linebacker with the New England Patriots. Undiagnosed brain injuries occur to the rich and famous, and also to our young soldiers who get very little respect, pay and fame. Not just to linebackers.

Read another of our stories about veterans, or read the source articles by Alessandra Stanley in the New York Times yesterday and by Gregg Zoroya in USA Today.