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Desensitized to Death
Could the death of Joan Rivers be a wake-up call for surgical facilities?
O
ur final speaker's final few PowerPoint slides at last month's
OR Excellence Conference in San Antonio began and ended
with a damning question:
What killed Joan Rivers?
We did.
Our industry did.
It was completely unnecessary.
It was preventable.
And can you believe we'll do it to another
439,999 people this year?
With that, you could hear a pin drop in the
main ballroom at the San Antonio Marriott Rivercenter as anesthesiol-
ogist and patient safety advocate Kenneth Rothfield, MD, MBA, CPE,
closed out ORX VII with a sensational talk, "Lessons Learned from
the Death of Joan Rivers: Ensuring Patient Safety in Outpatient
Surgery." After an uneasy moment of silence, the audience broke into
well-deserved applause. It's hard to clap when you've just been indict-
ed.
More than 400,000 U.S. citizens die from preventable medical errors
each year. Imagine if we heard about 2 747 crashes every single day.
That's what we're dealing with — well more than 1,000 preventable
deaths a day. Yet we virtually never hear about it, until someone like
Joan Rivers dies. We should be hearing about it. We should hear about
every preventable medical error immediately after it happens.
Right now we don't, for a number of reasons. First, there's the way
we talk about it. A surgeon clips the aorta or an anesthesiologist acci-
dentally doubles a medication dose, or an unmonitored patient goes
into respiratory failure in the PACU, and we call it a "complication."
E D I T O R ' S P A G E
Dan O'Connor