Never Events

"Who else is going to die today? Who else is going to be harmed today?" ~ Michele Monserratt-Ramos, patient safety activist

When Angela Asatrian, a social worker and filmmaker, found out her friend Ojan was a victim of severe medical negligence during a routine cyst removal, she was outraged and took action. Angela flew around the country to interview survivors of medical harm and patient safety experts. Never Events, a must see film, educates about the scope and frequency of medical harm, which is a lead cause of death and injury in the United States.

A Never Event is serious medical harm, (i.e.operating on a wrong body part), that should not occur if safety procedures are followed. Everyone Angela interviewed shared heartbreaking stories that elucidate the failure of our system. When a doctor commits a Never Event they are often not held to account; victims suffer and the public remains at risk.

Angela focuses in on a law in California, (and 32 other states), that caps non-economic damages for pain and suffering caused by medical harm in CA at $250,000. The cap has not been adjusted for inflation in 46 years. This Medical Injury Compensation Reform Act, (MICRA), was signed into law in response to a perceived - but later discredited - crisis. It was, in effect, dirty politics that benefits doctors and insurance companies, and impedes public safety. An insurance commissioner explained we need robust regulation, not this cap, to keep prices down.

Barry Keene, who created the bill, said it was his intention for MICRA to adjust for inflation. It's clear from survivor interviews MICRA is a cruel law that hinders victims of medical harm from going to court, obtaining justice and needed restitution, and stopping offenders. Trial cost can be $100,000; attorneys have to spend their own money on a case. Many lawyers say:

Medical treatment goes wrong often Doctors hide their bad reviews Doctors cover for each other The perception of the jury is that doctors are god The cases aren't financially worth it to them

Additionally, defense lawyers impose gags that prohibit survivors from speaking about their cases. Not mentioned are the 'Release Of All Claims' under-limit agreements for $29,999.99 with non-disclosure clauses. Why $29,999.99? Because at $30,000 a case is reported to the medical board and made public. This secretive system is abusivive and creates ongoing medical harm.

In the film, we meet a family who is working to increase transparency by creating a law that will mandate cameras in the operating room at the patient's request. Cameras in the O. R. could prevent some adverse events and even clear people who were present, but hospitals likely will not be for this. In 2015, Ethel Easter recorded her operation by hiding a camera in her hair. The tape revealed the surgical team degrading her during the procedure.

I support cameras in the O. R. In addition, I believe medical records should be co-authored by doctor and patient / approved by the patient. Looking to a doctor's records is a futile way to determine guilt. For legal purpose, if it's not in the medical record, it "never happened." This is a legal veil to protect doctors. In cases of medical abuse, notes may be wrong to begin with; it is the fall back position to alter records and photos to create a story offenders wish to convey.

Medical Board websites may show a doctor's profile to be clean, even if there is a history of felony arrests or medical malpractice. This misleads the public and gives a false sense of security. Even in cases with overwhelming evidence, the doctor controlled medical board often refuses to bring valid and egregious cases to investigation or a just conclusion. The offending doctors remain in practice.

Lars Anning, M. D, a doctor who confessed to Marshall Allen of ProPublica that he lied to protect his colleague in a malpractice suit now works to expose the corruption in the medical field. Dr. Anning says, "In my opinion, state medical boards are simply the enforcers of, and disciplinary agents for, corporate health care and don't give a damn about harmed patients. This sad situation is likely due to the incredible power of lawyers on the state medical boards (often linked to that state's attorney general office) and their professional links to the lawyers of corporate healthcare."

It is said several times in the film that studies show medical errors in hospitals are the third lead cause of death in the U. S. Up to 440,000 people a year may die in hospitals, which is equivalent to a 9/11 catastrophic loss every week. The word errors minimizes the gross negligence, surgical battery, medical scams, and unscrupulous cover-ups common in the field. The studies don't mention medical harm caused by doctors in privately owned ambulatory centers. I know 100s of people for whom doctors caused horrific injuries, traumas, and life-long disabilities that do not result in death.

Increased overhead leads some doctors to get into the cash pay sector. The self-pay sector turns practitioners into salespeople with menus of procedures to offer to a healthy population. Many cosmetic procedures ignore science, have poor risk-to-benefit ratios, and make healthy people worse or dead. This harm is systemically denied, silenced, and covered-up. Procedures based on profits instead of patient well being is the cause of much medical harm. Cosmetic, reconstructive, and other procedures often take place in private outpatient centers and offices, not hospitals.

California is the only state with more than 1,000 surgery centers that has given private accreditors a lead role in oversight. Those accreditors are typically paid by the same centers they evaluate. This approach to oversight has created a troubling legacy of laxity, Kaiser Health News shows. In case after case, as federal or state authorities waved red flags, state-approved accreditation agencies affixed gold seals of approval, according to a KHN review of hundreds of pages of doctors' disciplinary records, court files and accreditor reports, which are public only for CA surgery centers.

Suggestins given to increase one's chance for a safe outcome are a good place to start, though some may be misleading and give a false sense of security. I've studied medical harm done in ambulatory centers for almost a decade. 100s of people I've met who were harmed in outpatient centers or private offices were misled by online searches; there are websites and medical societies that fill the media with propaganda that is taken as truth. This creates a bandwagon effect. Websites favored by Google that feature doctor-experts kick people off who challenge the status quo and share about their bad outcomes. Review sites may offer packages to businesses to control their reviews, some reviews are paid for, and doctors have threatened and / or sued patients for writing the truth.

At the end of the film, several people talk about how the vast majority of doctors are good, competent, and caring; that is their opinion. The fact is, medical harm is a a national crisis; denial and cover-ups are the norm. Without accurate data, clear statistics are unknown. Cover-ups prevents "root cause analysis" needed to make errors and negligence less likely, like they do in aviation.

Some doctors intentionally misdiagnose people who were healthy and highly functional before medical harm with 'factious disorder' or other made up problems to cover for themselves or a peer instead of reporting the medical harm. It is not hard to look, listen, report, and do no harm, but many doctors refuse to do so. "Mental disorders become the default position to deal with medical uncertainty," said Dr. Allen Frances, former chair of psychiatry at the Duke University School of Medicine. "It's widespread, and it's dangerous."

Never Events is a must-see film. These compelling stories of medical harm are outrageous and unacceptable. The dirty politics of the tort reform cap is presented clearly. Thanks to everyone who participated.