Blog Article: Who’s In Charge? Searching for Answers in a Broken Healthcare System

By: Olivia Lounsbury, Patient Safety Movement Foundation

The coronavirus has pulled the band-aid off of our healthcare system and has exposed the system’s failures. Under normal circumstances, 220,000-440,000 people die from medical errors each year in U.S. hospitals. Paired with the chaos induced by the COVID pandemic, the mistakes occurring on a grand scale before are now amplified. Without families being allowed into their loved ones rooms, we have now taken the ability for patient and family members to advocate out of the equation. 

“Are COVID-19 patients being sent home or asked to stay home to quarantine when in fact they meet the criteria to be hospitalized?” 

“When were her vitals last taken?” 

“Do you know when we will be allowed to see him?”

“When was the last time her catheter port was cleaned?”

It’s not uncommon for patients and family members to be left with questions in which the hunt for answers leads to dead ends or conflicting information. The COVID-19 crisis has exacerbated this problem, as visitors are now restricted, the healthcare system is facing circumstances which require innovative thinking and quick reactions, and staff in leadership are working to sustain operations at the most basic level while dealing with the massive influx of pandemic patients. As such, COVID-19 has amplified visibility of problems in our healthcare system that have been manifesting covertly for decades. The lack of transparency, absence of a culture of safety, and existence of multiple governing bodies enables the continuation of medical errors, confusion, and frustration, exacerbated in the current crisis.

Since losing his daughter in 2012 due to multiple medical errors, Tony Galbo tenaciously tried to have his questions answered. Throughout his navigation through the US healthcare system, Tony’s demand for information was met with voicemails, unanswered emails, constant referrals, and conflicting information… or lack thereof. While it took years to understand the circumstances that ultimately led to his daughter’s death, his journey unveiled the brokenness of the medical system under which all of us will soon operate in one way or another. 

National Institute of Health, Center for Disease Control and Prevention, Centers for Medicare and Medicaid… The list could extend for the better portion of this excerpt and this extensive list should prompt inquisition and curiosity about the fragmentation inherent in US medicine today. There is no federal agency that regulates hospitals and healthcare workers like the FAA regulates airports, pilots and airlines. With all of these governing bodies, it’s no wonder Tony’s endeavor for information took years and the tenacity I could only wish to have. By putting myself into his shoes, the first question that would be at the forefront would be “Who’s in charge?” Without a single system, under which all practices are regulated and standards are communicated, how can we ensure that medical practices operate with the utmost quality and consistency? How can we evaluate how successful the healthcare accreditation agencies have been? How do we determine if there is a conflict of interest in this relationship? 

The lack of universal leadership leads to inevitable fragmentation, lack of standardization in process, and ultimately, cost the Galbo family their little girl. Tony’s story is by no means a fluke event. The absence of strong leadership, process management, and regulation leads to thousands of deaths and adverse events annually. If we are to continue asking “Who’s in charge?”, the next medical circumstance, whether a pandemic or a single car accident, will inevitably lead to gaps in care and compromise the quality of medicine. “When it comes to life and death, there is no tomorrow. Human lives are not disposable, and no life should be at the mercy of someone else’s needless mistakes and or negligence.”