Do No Harm: Patient Safety Reform Through Transparency and Accountability
(Editor's note: This blog post was written by AAJ Member, Robert Gellatly)
In the plaintiffs’ bar, our first duty is to seek justice for our clients, to right individual wrongs. But far too often, the wrongs inflicted are anything but singular—they represent systemic or institutional failures that pose grave risk to others.
With each failure comes the opportunity for positive change. When we use the justice system as a tool for instituting transparency and accountability, we establish the groundwork for change on a human scale that reaches far beyond any one person or case.
Our remarkable client August de los Reyes illustrates this perfectly. A nationally renowned design visionary – formerly head of design at Microsoft’s Xbox – August brought the full spectrum of knowledge, skill and confidence to advocate for his care when he walked in to his local hospital’s emergency room four times over two weeks in 2013, accurately diagnosing himself with a fractured spine. It didn’t matter. A chilling cascade of medical errors left him permanently paralyzed all the same.
The provider miscues and miscommunications that led to August’s injury are tragically common. This year, Johns Hopkins researchers estimated that more than 250,000 people die due to medical errors each year – making it the third leading cause of death nationwide. Particularly troubling is that we don’t truly know how many of these cases there are. As NPR writes, “the coding system used by CDC to record death certificate data doesn’t capture things like communication breakdowns, diagnostic errors and poor judgments that cost lives.”
Far too often, the confidentiality agreements that accompany settlements in cases like August’s only cast a shadow on already opaque practices. Medical records remain sealed and unread; promises of reform go unfulfilled; and the human toll continues to swell.
When my partners and I first explained our firm’s decades-long policy barring confidentiality agreements to August, he immediately grasped the implication: by eschewing confidentiality, he would be free to shine a light on his experience and help educate others.
August didn’t stop there. As part of his $20 million settlement with the provider, he specifically requested that hospital executives partner with him to analyze exactly what had happened, devise a plan for reform, and – in the words of his native technology industry – open-source the solution.
In the weeks following his settlement, August met with local healthcare leaders and began forming a national coalition to approach medical errors and patient safety as a system design issue. Others have found inspiration in August’s story; former patients reaching out with their own experiences, safety advocates eager to collaborate.
By coupling his tireless resolve with a broader vision of transparency and a willingness to work across the table, August is driven to reform patient safety and ensure that no one has to endure what he experienced. There’s no doubt that he faces a daunting task but, just by turning on the light, he has already made a meaningful impact and shaped the conversation on patient safety.
All across America, patients like August are at risk, their lives balancing on the whims of something as innocuous as a stray piece of paperwork.
We can’t afford to continue the years of living – and dying – dangerously, stumbling in the dark. Like August, let’s use our justice system to institute transparency and tackle a massive public safety issue. It’s time to hold the health care industry to the same standard we hold all others – requiring providers to share data and adverse patient outcomes publicly, rather than stashing them away. This is the only way to create solutions that help all patients, not just one.
About the Author
Robert Gellatly has been a trial lawyer for more than 25 years, handling a wide variety of personal injury and medical malpractice cases in state and federal courts. After defending lawsuits against hospitals, doctors and product manufacturers, he joined Luvera Law Firm in 2000 to devote his practice entirely to representing injured people. He is listed in the Best Lawyers in America, was named Best Lawyers 2015 Plaintiff’s Medical Malpractice Lawyer of the Year in Seattle, and received the Washington State Chapter of the American Board of Trial Advocates “Trial Lawyer of the Year” award in 2009.