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Patient safety and improved quality of care have become priority issues in the American healthcare system. The potential for medical errors was highlighted in 1999 when the Quality of Health Care in America Committee of the Institute of Medicine (IOM) published its first report, To Err is Human: Building a Safer Health System. The committee estimated that between 44,000 and 98,000 people die annually from inpatient medical errors. The eighth leading cause of death in this country, preventable medical errors, cost the U.S. approximately $17 billion annually in direct and indirect costs (IOM). These alarming statistics in the IOM report ignited the patient safety movement (I).
The IOM report made a series of recommendations that included the creation of a center for patient safety, the development of a national public reporting system, the establishment of oversight agencies, and the incorporation of safety principles into monitoring systems. Public and private agencies have responded with a series of initiatives that address these recommendations (See Table 1).
One healthcare expert describes three reasons as to why the potential for medical errors has increased. First, technology has created a sophisticated array of test, x-rays, laboratory procedures, and diagnostic tools. Second, pharmaceutical research has introduced thousands of new medications to the marketplace. Finally, specialization has led to experts, both physician and non-physician, in a wide range of body systems, diseases, settings, procedures, and therapies. Hospital medicine represents a new type of medical specialty that has the potential to address this increased complexity and sophistication and to improve patient care in the hospital inpatient environment (2).
Hospitalists as Team Coordinators
To achieve maximum positive outcomes in the complex inpatient environment, a qualified coordinator must educate others and facilitate activity revolving around patient care. Hospitalists as inpatient experts possess the necessary qualifications to integrate hospital systems and maximize efforts to enhance patient safety by monitoring medication distribution, chairing pharmaceuticals and therapeutics (P&T) committees, overseeing computerized physician order entry (CPOE), directing quality/performance improvement projects, and collaborating with discharge planning and case management.
Lakshmi Halasyamani, MD, is vice chair of the department of Internal Medicine at St. Joseph Mercy Hospital in Michigan and chairperson of the Society of Hospital Medicine (SHM) Hospital Quality and Patient Safety Committee. She says, Hospitalists have a ‘lens of understanding the systems under which they care for patients.’ They take care of patients in the hospital every single day so they can examine the processes with which they work. Hospitalists have an ideal perspective from which to reform ineffective systems.”
In spite of all the guidelines established by federal agencies and expert groups, Dr. Halasyamani points out that implementation barriers exist that prevent well-intentioned protocols and best practices from being carried out. Part of the challenge is the performance of a critical piece of the infrastructure—the multidisciplinary team. The very nature of healthcare demands an inherent need to coordinate and communicate. “Treating the patient is not the responsibility of one single individual,” says Halasyamani. “This is a team effort. The hospitalist recognizes that he is part of that team.” By elevating the ideals of teamwork, hospitalists can deliver to the patients the essential care that patients need, both while in the hospital and after they are discharged. In managing hospital inpatients, physicians must cope with high intensity of illness, pressures to reduce length of stay (LOS), and the coordination of handoffs among many specialists. According to Halasyamani, this can be a “recipe for disaster.”
Halasyamani acknowledges the vital role of protocols in reducing medical errors and improving quality of care. The training, education, and experience a hospitalist has acquired enables him to optimize communication and implement protocols, thus facilitating the practice of delivering safe and consistent care to all patients. In fact, with this smaller core group of inpatient physicians, the development and implementation of protocols can potentially be more effective because it targets a smaller group of physicians than the traditional inpatient model (8).
Kaveh C. Shojania, MD, is assistant professor of medicine at the University of Ottawa and co-author of Internal Bleeding: The Terrifying Truth Behind America's Epidemic Medical Mistakes. He points out that the current inpatient medical landscape involves a significant number of clinicians who practice at the hospital but not all their activity is centered there. “From a clinical perspective, no one has ownership,” he says. “On the other hand, hospitalists are based in a single hospital and have a vested interest in that particular hospital.” Typically generalists, hospitalists tend to interact with all specialists and therefore have a good sense of all interests.
Medical errors occur most often during transition times, from the ICU to the floor or from inpatient to outpatient status. There is the potential for a loss of clinical information during these transfers. According to Shojania, a significant portion of the hospitalist’s time is spent managing these transitions and overseeing patients as they are relocated from floor to floor and discharge to home, rehabilitation facility, or nursing home. He notes that the regulatory agencies have begun to acknowledge the importance of hospitalists. “The JCAHO (Joint Commission for the Accreditation of Healthcare Organizations) recognizes hospitalists as a resource because they are always in the hospital and have a vested interest,” he says (9).
Stakeholder Analysis
Patients stand to gain the most benefit from hospitalists insofar as safety and quality of care is concerned. Through the efforts and oversight of hospitalists, patients may experience reduced medical errors and lower mortality rates. For primary care physicians and hospitals, this lower rate of medical error means fewer medical malpractice cases, the potential for lower insurance premiums and, as a result, enhanced reputations. When hospitals are run more efficiently and provide a greater sense of trust and efficient management practices, society in general becomes the benefactor.
Clinical Trials
To date, few research studies measuring the impact of hospitalists on patient safety and quality of care have been conducted. Quality of care has been assessed largely through the surrogate markers of mortality and readmission rates. One study showed decreased in-hospital and 1-year mortality rates for hospitalist patients (10), and another indicated a decrease in 30-day readmission rates (11).
In addition, data from individual programs demonstrate positive findings. For example, Stacy Goldsholl, MD, medical director of the Covenant Healthcare hospital medicine program in Michigan, reports a 17% decrease in the expected mortality rate in the first year of the hospital medicine program. The information was drawn from the Michigan Hospital Association (MHA) databank and matched for severity and diagnosis (See Table 2). “This was significant when compared to the internal medicine comparison group with similar case mix index (CMI),” says Goldsholl. “In the first half of our second year, we have demonstrated a 46% decrease in expected mortality, while internal medicine had a 4% increase” (12).
Additionally, Goldsholl reports that Covenant initiated a Code Blue and emergency consult service to improve patient outcome and experienced a marked increase in efficiency. Table 3 represents elementary data collected during the first 6 months pre- and post-initiation of the hospital medicine program at Covenant (12).
Conclusion
Patient safety and quality of care in the hospital require a team of dedicated people to effect change. Orchestrating the team effectively is the responsibility of an attending physician. With the numerous “handoffs” that take place during hospitalization, the potential for medical errors increases exponentially. Federal mandates requiring the conversion to electronic medical records, which includes basic health information as well as critical data regarding medications, procedures, and surgeries, further complicates efficient and safe patient management. According to Robert Wachter, “Those doctors with the best outcomes were those who tended to treat similar patients with similar problems using similar techniques.” By definition, the hospitalist is a “physician who focuses his practice on the care, coordination, and safety of hospitalized patients.” Who better to stand at the center of the issue of reduced medical errors, improved patient care, and enhanced quality of care than hospitalists (13)?
Dr. Pak can be contacted at mhp@medicine.wisc.edu.
References
- To Err is Human: Building a Safer Health System, Institute of Medicine, November 1999.
- Wachter R. The end of the beginning: patient safety five years after ‘To Err Is Human.’ Health Affairs. November 30, 2004.
- Mission Statement: Center for Quality Improvement and Patient Safety. February 2004. Agency for Healthcare Research and Quality, Rockville, MD. www.ahrq.gov/about/cquips/cquipsmiss.htm.
- Safe Practices for Better Healthcare: a Consensus. The National Quality Forum, 2003.
- Joint Commission for Accreditation of Healthcare Organizations (JCAHO), www.jcaho.org.
- Leapfrog Group, www.leapfroggroup.org.
- Accreditation Council for Graduate Medical Education (ACGME), www.acgme.org.
- Halasyamani L. Telephone interview. February 7, 2005.
- Shojania KG. Assistant professor of medicine, University of Ottawa. Telephone interview. January 31, 2005.
- Auerbach AD, Wachter RM, Katz P. et al. Implementation of a voluntary hospitalist service at a community teaching hospital: improved clinical efficiency and patient outcomes. Ann Intern Med. 2002;137:859-65.
- Kulaga ME, Charney P, O’Mahoney SP, et al. The positive impact of initiation of hospitalist clinician educators. J Gen Intern Med. 2004;19:293-301.
- Goldsholl S. Medical director. Covenant Healthcare hospital medicine program, Saginaw, Michigan, email interview. January 31, 2005.
- Wachter R, Shojania K. Internal bleeding: the truth behind America’s terrifying epidemic of medical mistakes. Rugged Land, LLC, 2004.
Patient safety and improved quality of care have become priority issues in the American healthcare system. The potential for medical errors was highlighted in 1999 when the Quality of Health Care in America Committee of the Institute of Medicine (IOM) published its first report, To Err is Human: Building a Safer Health System. The committee estimated that between 44,000 and 98,000 people die annually from inpatient medical errors. The eighth leading cause of death in this country, preventable medical errors, cost the U.S. approximately $17 billion annually in direct and indirect costs (IOM). These alarming statistics in the IOM report ignited the patient safety movement (I).
The IOM report made a series of recommendations that included the creation of a center for patient safety, the development of a national public reporting system, the establishment of oversight agencies, and the incorporation of safety principles into monitoring systems. Public and private agencies have responded with a series of initiatives that address these recommendations (See Table 1).
One healthcare expert describes three reasons as to why the potential for medical errors has increased. First, technology has created a sophisticated array of test, x-rays, laboratory procedures, and diagnostic tools. Second, pharmaceutical research has introduced thousands of new medications to the marketplace. Finally, specialization has led to experts, both physician and non-physician, in a wide range of body systems, diseases, settings, procedures, and therapies. Hospital medicine represents a new type of medical specialty that has the potential to address this increased complexity and sophistication and to improve patient care in the hospital inpatient environment (2).
Hospitalists as Team Coordinators
To achieve maximum positive outcomes in the complex inpatient environment, a qualified coordinator must educate others and facilitate activity revolving around patient care. Hospitalists as inpatient experts possess the necessary qualifications to integrate hospital systems and maximize efforts to enhance patient safety by monitoring medication distribution, chairing pharmaceuticals and therapeutics (P&T) committees, overseeing computerized physician order entry (CPOE), directing quality/performance improvement projects, and collaborating with discharge planning and case management.
Lakshmi Halasyamani, MD, is vice chair of the department of Internal Medicine at St. Joseph Mercy Hospital in Michigan and chairperson of the Society of Hospital Medicine (SHM) Hospital Quality and Patient Safety Committee. She says, Hospitalists have a ‘lens of understanding the systems under which they care for patients.’ They take care of patients in the hospital every single day so they can examine the processes with which they work. Hospitalists have an ideal perspective from which to reform ineffective systems.”
In spite of all the guidelines established by federal agencies and expert groups, Dr. Halasyamani points out that implementation barriers exist that prevent well-intentioned protocols and best practices from being carried out. Part of the challenge is the performance of a critical piece of the infrastructure—the multidisciplinary team. The very nature of healthcare demands an inherent need to coordinate and communicate. “Treating the patient is not the responsibility of one single individual,” says Halasyamani. “This is a team effort. The hospitalist recognizes that he is part of that team.” By elevating the ideals of teamwork, hospitalists can deliver to the patients the essential care that patients need, both while in the hospital and after they are discharged. In managing hospital inpatients, physicians must cope with high intensity of illness, pressures to reduce length of stay (LOS), and the coordination of handoffs among many specialists. According to Halasyamani, this can be a “recipe for disaster.”
Halasyamani acknowledges the vital role of protocols in reducing medical errors and improving quality of care. The training, education, and experience a hospitalist has acquired enables him to optimize communication and implement protocols, thus facilitating the practice of delivering safe and consistent care to all patients. In fact, with this smaller core group of inpatient physicians, the development and implementation of protocols can potentially be more effective because it targets a smaller group of physicians than the traditional inpatient model (8).
Kaveh C. Shojania, MD, is assistant professor of medicine at the University of Ottawa and co-author of Internal Bleeding: The Terrifying Truth Behind America's Epidemic Medical Mistakes. He points out that the current inpatient medical landscape involves a significant number of clinicians who practice at the hospital but not all their activity is centered there. “From a clinical perspective, no one has ownership,” he says. “On the other hand, hospitalists are based in a single hospital and have a vested interest in that particular hospital.” Typically generalists, hospitalists tend to interact with all specialists and therefore have a good sense of all interests.
Medical errors occur most often during transition times, from the ICU to the floor or from inpatient to outpatient status. There is the potential for a loss of clinical information during these transfers. According to Shojania, a significant portion of the hospitalist’s time is spent managing these transitions and overseeing patients as they are relocated from floor to floor and discharge to home, rehabilitation facility, or nursing home. He notes that the regulatory agencies have begun to acknowledge the importance of hospitalists. “The JCAHO (Joint Commission for the Accreditation of Healthcare Organizations) recognizes hospitalists as a resource because they are always in the hospital and have a vested interest,” he says (9).
Stakeholder Analysis
Patients stand to gain the most benefit from hospitalists insofar as safety and quality of care is concerned. Through the efforts and oversight of hospitalists, patients may experience reduced medical errors and lower mortality rates. For primary care physicians and hospitals, this lower rate of medical error means fewer medical malpractice cases, the potential for lower insurance premiums and, as a result, enhanced reputations. When hospitals are run more efficiently and provide a greater sense of trust and efficient management practices, society in general becomes the benefactor.
Clinical Trials
To date, few research studies measuring the impact of hospitalists on patient safety and quality of care have been conducted. Quality of care has been assessed largely through the surrogate markers of mortality and readmission rates. One study showed decreased in-hospital and 1-year mortality rates for hospitalist patients (10), and another indicated a decrease in 30-day readmission rates (11).
In addition, data from individual programs demonstrate positive findings. For example, Stacy Goldsholl, MD, medical director of the Covenant Healthcare hospital medicine program in Michigan, reports a 17% decrease in the expected mortality rate in the first year of the hospital medicine program. The information was drawn from the Michigan Hospital Association (MHA) databank and matched for severity and diagnosis (See Table 2). “This was significant when compared to the internal medicine comparison group with similar case mix index (CMI),” says Goldsholl. “In the first half of our second year, we have demonstrated a 46% decrease in expected mortality, while internal medicine had a 4% increase” (12).
Additionally, Goldsholl reports that Covenant initiated a Code Blue and emergency consult service to improve patient outcome and experienced a marked increase in efficiency. Table 3 represents elementary data collected during the first 6 months pre- and post-initiation of the hospital medicine program at Covenant (12).
Conclusion
Patient safety and quality of care in the hospital require a team of dedicated people to effect change. Orchestrating the team effectively is the responsibility of an attending physician. With the numerous “handoffs” that take place during hospitalization, the potential for medical errors increases exponentially. Federal mandates requiring the conversion to electronic medical records, which includes basic health information as well as critical data regarding medications, procedures, and surgeries, further complicates efficient and safe patient management. According to Robert Wachter, “Those doctors with the best outcomes were those who tended to treat similar patients with similar problems using similar techniques.” By definition, the hospitalist is a “physician who focuses his practice on the care, coordination, and safety of hospitalized patients.” Who better to stand at the center of the issue of reduced medical errors, improved patient care, and enhanced quality of care than hospitalists (13)?
Dr. Pak can be contacted at mhp@medicine.wisc.edu.
References
- To Err is Human: Building a Safer Health System, Institute of Medicine, November 1999.
- Wachter R. The end of the beginning: patient safety five years after ‘To Err Is Human.’ Health Affairs. November 30, 2004.
- Mission Statement: Center for Quality Improvement and Patient Safety. February 2004. Agency for Healthcare Research and Quality, Rockville, MD. www.ahrq.gov/about/cquips/cquipsmiss.htm.
- Safe Practices for Better Healthcare: a Consensus. The National Quality Forum, 2003.
- Joint Commission for Accreditation of Healthcare Organizations (JCAHO), www.jcaho.org.
- Leapfrog Group, www.leapfroggroup.org.
- Accreditation Council for Graduate Medical Education (ACGME), www.acgme.org.
- Halasyamani L. Telephone interview. February 7, 2005.
- Shojania KG. Assistant professor of medicine, University of Ottawa. Telephone interview. January 31, 2005.
- Auerbach AD, Wachter RM, Katz P. et al. Implementation of a voluntary hospitalist service at a community teaching hospital: improved clinical efficiency and patient outcomes. Ann Intern Med. 2002;137:859-65.
- Kulaga ME, Charney P, O’Mahoney SP, et al. The positive impact of initiation of hospitalist clinician educators. J Gen Intern Med. 2004;19:293-301.
- Goldsholl S. Medical director. Covenant Healthcare hospital medicine program, Saginaw, Michigan, email interview. January 31, 2005.
- Wachter R, Shojania K. Internal bleeding: the truth behind America’s terrifying epidemic of medical mistakes. Rugged Land, LLC, 2004.
Patient safety and improved quality of care have become priority issues in the American healthcare system. The potential for medical errors was highlighted in 1999 when the Quality of Health Care in America Committee of the Institute of Medicine (IOM) published its first report, To Err is Human: Building a Safer Health System. The committee estimated that between 44,000 and 98,000 people die annually from inpatient medical errors. The eighth leading cause of death in this country, preventable medical errors, cost the U.S. approximately $17 billion annually in direct and indirect costs (IOM). These alarming statistics in the IOM report ignited the patient safety movement (I).
The IOM report made a series of recommendations that included the creation of a center for patient safety, the development of a national public reporting system, the establishment of oversight agencies, and the incorporation of safety principles into monitoring systems. Public and private agencies have responded with a series of initiatives that address these recommendations (See Table 1).
One healthcare expert describes three reasons as to why the potential for medical errors has increased. First, technology has created a sophisticated array of test, x-rays, laboratory procedures, and diagnostic tools. Second, pharmaceutical research has introduced thousands of new medications to the marketplace. Finally, specialization has led to experts, both physician and non-physician, in a wide range of body systems, diseases, settings, procedures, and therapies. Hospital medicine represents a new type of medical specialty that has the potential to address this increased complexity and sophistication and to improve patient care in the hospital inpatient environment (2).
Hospitalists as Team Coordinators
To achieve maximum positive outcomes in the complex inpatient environment, a qualified coordinator must educate others and facilitate activity revolving around patient care. Hospitalists as inpatient experts possess the necessary qualifications to integrate hospital systems and maximize efforts to enhance patient safety by monitoring medication distribution, chairing pharmaceuticals and therapeutics (P&T) committees, overseeing computerized physician order entry (CPOE), directing quality/performance improvement projects, and collaborating with discharge planning and case management.
Lakshmi Halasyamani, MD, is vice chair of the department of Internal Medicine at St. Joseph Mercy Hospital in Michigan and chairperson of the Society of Hospital Medicine (SHM) Hospital Quality and Patient Safety Committee. She says, Hospitalists have a ‘lens of understanding the systems under which they care for patients.’ They take care of patients in the hospital every single day so they can examine the processes with which they work. Hospitalists have an ideal perspective from which to reform ineffective systems.”
In spite of all the guidelines established by federal agencies and expert groups, Dr. Halasyamani points out that implementation barriers exist that prevent well-intentioned protocols and best practices from being carried out. Part of the challenge is the performance of a critical piece of the infrastructure—the multidisciplinary team. The very nature of healthcare demands an inherent need to coordinate and communicate. “Treating the patient is not the responsibility of one single individual,” says Halasyamani. “This is a team effort. The hospitalist recognizes that he is part of that team.” By elevating the ideals of teamwork, hospitalists can deliver to the patients the essential care that patients need, both while in the hospital and after they are discharged. In managing hospital inpatients, physicians must cope with high intensity of illness, pressures to reduce length of stay (LOS), and the coordination of handoffs among many specialists. According to Halasyamani, this can be a “recipe for disaster.”
Halasyamani acknowledges the vital role of protocols in reducing medical errors and improving quality of care. The training, education, and experience a hospitalist has acquired enables him to optimize communication and implement protocols, thus facilitating the practice of delivering safe and consistent care to all patients. In fact, with this smaller core group of inpatient physicians, the development and implementation of protocols can potentially be more effective because it targets a smaller group of physicians than the traditional inpatient model (8).
Kaveh C. Shojania, MD, is assistant professor of medicine at the University of Ottawa and co-author of Internal Bleeding: The Terrifying Truth Behind America's Epidemic Medical Mistakes. He points out that the current inpatient medical landscape involves a significant number of clinicians who practice at the hospital but not all their activity is centered there. “From a clinical perspective, no one has ownership,” he says. “On the other hand, hospitalists are based in a single hospital and have a vested interest in that particular hospital.” Typically generalists, hospitalists tend to interact with all specialists and therefore have a good sense of all interests.
Medical errors occur most often during transition times, from the ICU to the floor or from inpatient to outpatient status. There is the potential for a loss of clinical information during these transfers. According to Shojania, a significant portion of the hospitalist’s time is spent managing these transitions and overseeing patients as they are relocated from floor to floor and discharge to home, rehabilitation facility, or nursing home. He notes that the regulatory agencies have begun to acknowledge the importance of hospitalists. “The JCAHO (Joint Commission for the Accreditation of Healthcare Organizations) recognizes hospitalists as a resource because they are always in the hospital and have a vested interest,” he says (9).
Stakeholder Analysis
Patients stand to gain the most benefit from hospitalists insofar as safety and quality of care is concerned. Through the efforts and oversight of hospitalists, patients may experience reduced medical errors and lower mortality rates. For primary care physicians and hospitals, this lower rate of medical error means fewer medical malpractice cases, the potential for lower insurance premiums and, as a result, enhanced reputations. When hospitals are run more efficiently and provide a greater sense of trust and efficient management practices, society in general becomes the benefactor.
Clinical Trials
To date, few research studies measuring the impact of hospitalists on patient safety and quality of care have been conducted. Quality of care has been assessed largely through the surrogate markers of mortality and readmission rates. One study showed decreased in-hospital and 1-year mortality rates for hospitalist patients (10), and another indicated a decrease in 30-day readmission rates (11).
In addition, data from individual programs demonstrate positive findings. For example, Stacy Goldsholl, MD, medical director of the Covenant Healthcare hospital medicine program in Michigan, reports a 17% decrease in the expected mortality rate in the first year of the hospital medicine program. The information was drawn from the Michigan Hospital Association (MHA) databank and matched for severity and diagnosis (See Table 2). “This was significant when compared to the internal medicine comparison group with similar case mix index (CMI),” says Goldsholl. “In the first half of our second year, we have demonstrated a 46% decrease in expected mortality, while internal medicine had a 4% increase” (12).
Additionally, Goldsholl reports that Covenant initiated a Code Blue and emergency consult service to improve patient outcome and experienced a marked increase in efficiency. Table 3 represents elementary data collected during the first 6 months pre- and post-initiation of the hospital medicine program at Covenant (12).
Conclusion
Patient safety and quality of care in the hospital require a team of dedicated people to effect change. Orchestrating the team effectively is the responsibility of an attending physician. With the numerous “handoffs” that take place during hospitalization, the potential for medical errors increases exponentially. Federal mandates requiring the conversion to electronic medical records, which includes basic health information as well as critical data regarding medications, procedures, and surgeries, further complicates efficient and safe patient management. According to Robert Wachter, “Those doctors with the best outcomes were those who tended to treat similar patients with similar problems using similar techniques.” By definition, the hospitalist is a “physician who focuses his practice on the care, coordination, and safety of hospitalized patients.” Who better to stand at the center of the issue of reduced medical errors, improved patient care, and enhanced quality of care than hospitalists (13)?
Dr. Pak can be contacted at mhp@medicine.wisc.edu.
References
- To Err is Human: Building a Safer Health System, Institute of Medicine, November 1999.
- Wachter R. The end of the beginning: patient safety five years after ‘To Err Is Human.’ Health Affairs. November 30, 2004.
- Mission Statement: Center for Quality Improvement and Patient Safety. February 2004. Agency for Healthcare Research and Quality, Rockville, MD. www.ahrq.gov/about/cquips/cquipsmiss.htm.
- Safe Practices for Better Healthcare: a Consensus. The National Quality Forum, 2003.
- Joint Commission for Accreditation of Healthcare Organizations (JCAHO), www.jcaho.org.
- Leapfrog Group, www.leapfroggroup.org.
- Accreditation Council for Graduate Medical Education (ACGME), www.acgme.org.
- Halasyamani L. Telephone interview. February 7, 2005.
- Shojania KG. Assistant professor of medicine, University of Ottawa. Telephone interview. January 31, 2005.
- Auerbach AD, Wachter RM, Katz P. et al. Implementation of a voluntary hospitalist service at a community teaching hospital: improved clinical efficiency and patient outcomes. Ann Intern Med. 2002;137:859-65.
- Kulaga ME, Charney P, O’Mahoney SP, et al. The positive impact of initiation of hospitalist clinician educators. J Gen Intern Med. 2004;19:293-301.
- Goldsholl S. Medical director. Covenant Healthcare hospital medicine program, Saginaw, Michigan, email interview. January 31, 2005.
- Wachter R, Shojania K. Internal bleeding: the truth behind America’s terrifying epidemic of medical mistakes. Rugged Land, LLC, 2004.