Dr. Death, a new series on Peacock, shares the story of Dr. Christopher Duntsch, a neurosurgeon who’s been nicknamed “Dr. Death” who was convicted after maiming dozens of patients and killing two while working in Texas. The Dr. Death case is rare, when harm occurs in the hospital it is mostly systemic issues that relate back to the health system and is very rarely a health worker who has intended to do harm. But, Dr. Duntsch wasn’t the first and won’t be the last.
We believe that it’s important to highlight this case as an example to learn from so that we can achieve ZERO preventable patient harm and death. The reason we’re addressing some of the issues that the Dr. Death series highlights is to raise awareness about some of the ways that Dr. Duntsch could have been caught earlier, if the system had been working properly. Below we share the role of the National Practitioner Data Bank (NPDB) and State Medical Boards (SMB) which did not capture Dr. Duntsch’s malfeasance. The problem in this case was that the administrators and health workers working alongside Dr. Duntsch did not report into the NPDB. The State Medical Board of Texas, however, did fail at doing their job protecting Dr. Duntsch, a neurosurgeon bringing in lots of money into the health system, over the patients who were trying to seek justice. We also discuss how we, here at the Patient Safety Movement Foundation, are driving a culture of safe and reliable care.
What is the National Practitioner Data Bank?
The National Practitioner Data Bank (NPDB) is operated by the U.S. Department of Health and Human Services. The NPDB is a database that contains information submitted by hospitals, healthcare organizations and state licensing boards (including State Medical Boards) about physicians and other health care practitioners. The type of information that is found in the NPDB includes restrictions placed on clinical privileges for individual practitioners, actions taken against physicians’ licenses as well as medical malpractice payments, among other variables.
Who Can Access the National Practitioner Data Bank’s Data?
Individual practitioner data is not publicly available and is restricted to “authorized users.” These authorized users include hospitals and healthcare organizations, health plans, state licensing boards, and medical malpractice payers and these entities use information from the NPDB to consider a practitioner’s application for hospital privileges or a state medical license. Other entities that may apply to query the database include professional societies as well as agencies or contractors that are administering Federal or State healthcare programs.
A Public Use Database containing de-identified statistical data is open to members of the public. This data is often used by researchers for statistical analysis but not very helpful to patients. Practitioners themselves are able to access their own records.
Why the Lack of Transparency?
Powerful associations and professional bodies that protect practitioners have lobbied to keep this information out of the public eye in the interest of individual practitioners.
How Culture Fits Into This Lack of Transparency
Helping to build a culture of safety in healthcare organizations, with open and honest reporting practices and a focus on continuous improvement, is happening slowly but surely in many healthcare facilities and health systems. If every organization tracked errors and near misses effectively, and eliminated the naming, shaming and blaming of individual practitioners, then there would be little need to report to a national data bank. However there needs to be accountability when established safe practices are not followed. So this is an alternative that the Patient Safety Movement Foundation is pushing forward – a model called Communication and Optimal Resolution (CANDOR). You can read more about our approach which is built on a foundation for a safe and reliable healthcare system.
Background on State Medical and Nursing Boards
State Medical Boards (SMBs) and State Nursing Boards (SNBs) are government agencies but the functions of them vary by state. Since these Boards are appointed by the state’s governor the funding, functions and the priorities of the boards are highly subjective. In general, the Boards oversee the licensing of medical doctors and nurses, investigate complaints, discipline health care providers who violate the medical practice act and refer them for evaluation and rehab when appropriate.
One of the major challenges of each state having different functions and priorities is that if a health care provider is disciplined in one state for one specific reason, or if a health care provider’s license is revoked in one state, they may well be able to move to another state to practice without breaking any of that state’s laws and slipping under the radar if the hospital in the new state doesn’t query the NPDB – as they are supposed to.
The Link between State Medical and Nursing Boards to the National Physician Data Bank
While hospitals, healthcare organizations and SMBs are required to report into and make inquiries into the NPDB to monitor and track physicians, the adherence is another story. The example above where a physician’s license is revoked in Alabama and moves to Florida relies on the hospital where the physician is seeking privileges to do their due diligence before they hire that doctor.
Public Information from State Medical Board Investigations
The public cannot see the outcome of any complaints to a state medical board unless a physician has been disciplined. However, when there has been a settlement sometimes all the details are concealed. One example is listed below for the state of California – where you can go to the Breeze License Verification page and query the name or license number of a medical doctor. Since most complaints are dismissed without disciplinary action, it is possible for a provider to have numerous complaints with no public record.
Conflicts of Interest
The other issue that affects the ability for SMBs to remain impartial and look out for the safety of patients as a priority relates to who is on the SMBs. The boards are often composed of physicians and other healthcare workers or industry professionals. This can create a conflict of interest when those boards are asked to investigate and discipline their peers, or stakeholders who they work with if they are from the healthcare industry.
Lack of Transparency
There’s no requirement in many states to make any information from the SMB meetings public which means that the results of investigations and the decisions may be kept in the dark.
The Three Key Concepts
We believe that there are 3 priorities that global leaders must take to address this global medical error crisis:
- Driving Safety Data Transparency.
- Aligning payment for healthcare services with safe treatment and outcomes to motivate hospitals to invest in patient safety. Give a carrot to those that do well; give a stick to those who need motivating.
- Establishing Region-appropriate Oversight. We encourage this in each country, globally.