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Archive for the ‘Patient safety’ Category

Death after being restrained by Pat Iyer

Wednesday, August 25th, 2010

The charge nurse found Alexis Evette Richie alone in a small room at SSM DePaul Health Center, motionless and sprawled facedown on a bean bag chair. Minutes earlier, the 16-year-old foster child had tried to hit, scratch and bite staff members in the adolescent psychiatric ward. Two aides grabbed her arms and took her down a hall and into a small room called the “quiet room.”

They held her facedown in the chair while a nurse injected a sedative into her hip. Alexis continued to struggle and then went limp. The nurse and the two aides left without checking her pulse or making sure she was breathing. Charge nurse Iris Blanks checked on her minutes later and didn’t think Alexis looked right. An aide helped Blanks roll the girl over. Alexis wasn’t breathing. Her pulse was faint. It was 12 minutes after she stopped moving before anyone tried to revive Alexis. By then it was too late.

Dr. Wanda Mohr and I did a teleseminar on the topic of death in restraints. She talked about a colleague of hers who did a study of pediatric deaths from restraints. Just simply looking at lawsuits and newspaper articles, within that 10-year period he found that 45 deaths had occurred and those deaths were specifically limited to children. The youngest child who had died was 6-year-old. The most common mechanism of death is restraint asphyxia. A person essentially asphyxiates or chokes to death. Her oxygen is cut off and that, most commonly, occurs in a prone position. This is associated with individuals actually putting pressure on people’s back and their lower back and despite their pleas that they were unable to breathe, the staff would not let the person up.

For a death in another treatment center, read about a 17-year-old boy who was strangled while being restrained.

One child dying of being restrained is far too many. There are safe ways to help agitated or violent people get back under control. Any healthcare provider working in a setting where this type of behavior could occur should know how to protect the patient (as well as the healthcare workers) from injury.

What are these?

Tags: Alexis Richie, asphyxiation, choking, death in restraints
Posted in Damages, Healthcare Risk Management, Patient safety, medical errors | No Comments »

When should nursing staff call a rapid response team? by Pat Iyer

Wednesday, August 4th, 2010

A sudden deterioration in a patient’s condition should stimulate activation of emergency efforts. The goal of a rapid response team (RRT) is to avert a cardiac arrest – to take action before the patient stops breathing. here are some generally accepted reasons to call a team of professionals to the bedside:

Staff worried about patient
Acute change in heart rate
Acute change in systolic blood pressure
Acute change in respiratory rate

a rapid response team could save your life

Acute drop in O2 saturation
Acute change in mental status
Drop in urine output
New, repeated, or prolonged seizures
Fractional inspired oxygen of 50% or greater
Failure to respond to treatment for an acute problem/symptoms

The composition of RRTs varies from hospital to hospital. A team typically consists of 2-3 people who are assigned to flexible responsibilities within the facility. The team may consist of respiratory therapists, physician assistants, nurse practitioners, critical care nurses, intensivist (critical care doctors), hospitalists (physicians employed within a facility to provide inpatient care) or residents. The team’s role is to assess and stabilize the patient, assist with communication with the attending physician, educate and support the nursing staff and family, and assist with transfer to another level of care, if needed.

The rapid response team serves a vital role, but not all hospitals have them. Does yours? Consider this important patient safety feature when you pick a hospital.

What are these?

Tags: cardiac arrest, intensivist, rapid response team, RRT
Posted in Healthcare Risk Management, Legal nurse consulting, Medical malpractice, Nursing malpractice, Patient safety, medical errors | No Comments »

Failure to rescue by Pat Iyer

Monday, August 2nd, 2010

Failure to rescue is a big source of patient injury

Imagine this scene: You are visiting your elderly father in the hospital when you notice his speech is becoming slurred and he is less awake than usual. Concerned, you call his nurse into the room. She assesses your father, then picks up the phone and requests an emergency response team. A team of professionals enter the room, assess and stabilize your father, and arrange for him to be transported to the ICU with a tentative diagnosis of rule out stroke. Your father’s attending physician is called as the team is completing its assessment. The critical care nurse on the team pulls the floor nurse aside to congratulate her on her astute assessment. The process from start to finish has taken 20 minutes.

Failure to rescue is a term that describes the outcome when a patient’s condition deteriorates before the changes are recognized and acted upon. Failure to rescue is a nursing-sensitive performance measure on the list of 15 identified by the National Quality Forum in 2004 to be collected by CMS (Centers for Medicare and Medicaid Services). A 2009 study performed by HealthGrades showed that patient safety incidents with the highest incidence rates were failure to rescue. There were 92.7 incidents (per 1,000 population). Starting June 1, 2010, CMS began collecting data about a facility’s failure to rescue rates.

The use of rapid response teams (RRTs) to provide timely rescue efforts in hospitals has gained momentum and popularity, although not all hospitals have them. The concept originated with a critical care nurse from New Zealand who recognized the need to bring resources to the bedside of a patient whose condition deteriorated before more serious events occurred. Without rapid response teams, nurses who recognize ominous changes in the status of their patients are forced to contact the attending physician and wait for a return call. Should an attending physician refuse to deal with or minimize the concerns of the nurse, the nurse has to use the chain of command within a facility – in effect, to go over the head of the attending physician with the assistance of nursing administration, to find a physician who will respond. This is a slow and difficult process.

RRTs have the capability of bypassing the attending physician to turn what can be a 2-3 hour long process into a 5-10 minute arrival to the patient’s bedside. The use of a team within a facility empowers the staff nurse, and provides a safety net for both the nurses and the patients. Implementation of RRTs has reduced cardiac arrests, deaths, the number of unexpected emergency admissions to ICU, and the length of a hospital admission for cardiac arrest survivors. RRTs build teamwork and spread knowledge and skills throughout the hospital. The goals of the team are to provide immediate detection and diagnosis, to treat patients early, and to mitigate harm by turning adverse events into “near misses”. The system is designed to protect the patient from further harm and to allow for recovery from possible medical errors and system deficiencies.

Is the RRT system working? A survey of 56 staff nurses identified the three categories of reasons for why the RRT was activated:

• The patient exhibited signs and symptoms that were either unexpected or significantly different from baseline.
• Despite the absence of objective data, the nurse had a “gut feeling” that “something was wrong.”
• The nurse was convinced that the patient needed immediate evaluation and was unable to get the treating physician to respond as the nurse thought necessary. This is what one nurse said:

“It’s during shift change so everybody’s calling and running and doing this and that, and we called the doctor and he said, ‘Well, she’s got a pulmonologist on the case, call them.’ He gave us nothing. No orders. No meds. No, no nothing. . . At that point we decided we’re not going to wait for anybody else, we’ll just call rapid response and get them down here.”

Consider this comment in comparison to the often slow process of obtaining medical attention when a facility does not have a RRT. In addition to the direct patient safety benefits of such teams, RRTs empowered nurses and gave them a sense of control over the patient situation, identified other processes negatively affecting patient safety, and improved communication and respect between disciplines, thereby raising job satisfaction.

Sources: Shapiro, S, Donaldson, N, and Scott, M. “Rapid response teams: seen through the eyes of the nurse”, AJN, June 2010, 110 (6), 28-34
www.healthgrades.com/media/dms/pdf/patientsafetyinamericanhospitalsstudy2009.pdf

Extracted from Patricia Iyer, Roots of Patient Injury, in Patricia Iyer, Barbara Levin, Kathleen Ashton and Victoria Powell, Nursing Malpractice, Fourth Edition, in press.

What are these?

Tags: cardiac arrest, failure to rescue, rapid response teams, RRTs
Posted in Emergency Medicine, Healthcare Risk Management, Legal nurse consulting, Nursing malpractice, Patient safety, medical errors | No Comments »

Why don’t healthcare providers follow the rules? Part 2 by Pat Iyer

Monday, July 19th, 2010

Wrong site surgery is the most common medical error

Wrong site surgery is the most common sentinel event

Normalization of deviance occurs when a provider, such as a nurse, knowingly disregards a safety practice, like using two patient identifiers to verify patient identity. Repeated deviation from the safe practices tends to “normalize” the risky behavior in the nurse’s mind. In another example, The Joint Commission Medication Management Standard requires labeling of all medications. Yet a survey by the American Nurses Association indicated that only 37 percent of nurses surveyed reported they always label syringes and 28 percent never label syringes when administering medications.

Despite awareness and education, some providers choose to willfully disregard safety practices. Patient safety experts define a “no blame” culture as one that argues that most errors are committed by hardworking people; the traditional focus on identifying who is at fault is a distraction. A “just culture” differentiates between blameworthy and blameless acts. Two physicians, Wachter and Pronovost, acknowledge that there are areas of performance that pose a clear risk to patients, such as failure to practice hand hygiene, use a checklist to reduce blood stream infections, mark the surgical site to prevent wrong-site surgery, or perform a preoperative time out.

Nurses are implicated in some of these issues. They work for the organization, which typically has relatively clear lines of authority and procedures for dealing with failure to follow accepted practices. On the other hand, physicians have traditionally been independent entrepreneurs, not employees. They are subject to weak peer enforcement. Peers often recoil from disciplining each other and hospitals have been reluctant to punish physicians for fear of alienating them and losing the business they bring in. The tradition of lax enforcement of safety rules has led too many physicians to ignore them. Wachter and Pronovost argued for a clear definition of unacceptable behaviors, with the initial warnings and counseling. Continued failure to adhere to safety practices after the initial penalty would lead to suspension or loss of clinical privileges (for physicians and others subject to credentialing, such as advanced practice nurses) or firing.

Isn’t it about time we stopped dangerous practices?

More reading:
Beaulieu, L. and Freeman, M, “Nursing shortcuts can shortcut safety”, Nursing 2009, December 2009, 16-20
Wachter, R. and Pronovost, P., “Balancing ‘no blame’ with accountability in patient safety”, New England Journal of Medicine, October 1, 2009, 1401-1406.
Cohen, M. “Risky imposter”, Nursing 2008, May 2008, 20.

What are these?

Tags: hand hygiene, hospital-acquired infection, medical errors, normalization of deviance, wrong site surgery
Posted in Healthcare Risk Management, Medical malpractice, Nursing malpractice, Patient safety, medical errors | No Comments »

Why don’t healthcare providers follow the rules? Part 1 by Pat Iyer

Wednesday, July 14th, 2010

Wrong site surgery is the most common medical error

I’ve been updating a chapter on the roots of patient injury for the fourth edition of Nursing Malpractice. I’ve been thinking about the reasons people don’t follow policies and procedures. Back in the 1980s when I ran a nursing hospital’s staff development department, I learned that if people did not have the knowledge, this was an educational problem and we were to educate. If they knew how to perform their jobs but chose not to, this was a management problem and their managers were to counsel and discipline. Now we think about this issue in expanded terms.

1. Safety standards are not monitored or enforced
People may not do their jobs correctly because there are no consequences if they don’t. Managers must be clear about the need to follow policies and procedures and the consequences of not doing so. Continual monitoring and education about the importance of patient safety sends an obvious message about the value of patient safety policies.

2. Lack of knowledge
Staff may be unaware of how to perform aspects of their job. They need training and competency checks. They may lack knowledge about how medical errors occur. Integration of patient safety information into the curriculum of schools of nursing helps to increase knowledge and skills.

3. Dysfunctional systems
Convoluted systems are sometimes created by providers or administrators who lack essential training in human factors and systems engineering, which may make it too hard to adhere to the practice. This invites workarounds because it becomes too difficult to follow the procedures.

What are these?

Tags: hand hygiene, medical errors, normalization of deviance, Patient safety, wrong site surgery
Posted in Healthcare Risk Management, Medical malpractice, Nursing malpractice, Patient safety, medical errors | No Comments »

Prescription drug overdoses on the rise in U.S.

Monday, June 7th, 2010

by Megan Brooks
(Reuters Health) – More and more Americans are landing in the hospital due to poisoning by powerful prescription painkillers, sedatives and tranquilizers, according to a report released American Journal of Preventive Medicine, April 2010. City-living middle-aged women seem particularly vulnerable.
People have seen the headlines related to Heath Ledger, Michael Jackson, Anna Nicole Smith and they think that’s tragic but maybe contained to Hollywood,” Dr. Jeffrey H. Coben of West Virginia University School of Medicine in Morgantown told Reuters Health. “But the fact of the matter is we are seeing, across the country, very significant increases in serious overdoses associated with these prescription drugs,” Coben warned.

Between 1999 and 2006, US hospital admissions due to poisoning by prescription opioids, sedatives and tranquilizers rose from approximately 43,000 to about 71,000. That increase of 65 percent is about double the increase observed in hospitalizations for poisoning by other drugs and medicines, Coben and colleagues found.

Opioids — examples include morphine, methadone, OxyContin and the active ingredient in Percocet — are powerful narcotic painkillers that can be habit-forming. Some examples of sedatives or tranquilizers include Valium, Xanax, and Ativan.

What’s behind the rise in poisoning by prescription painkillers, sedatives and tranquilizers? “There is not any single cause,” Coben said. “There is increasing availability of powerful prescription drugs in the community and attitudes toward their use tend to be different than attitudes toward using other drugs, especially among young people, who report that prescription drugs are easy to obtain, and they think they are less addictive and less dangerous than street drugs like heroin and cocaine.”
Read more

What are these?

Tags: drug overdose, Medication errors, medication overdoses, narcotics, opioid overdose
Posted in Damages, Medication errors, Patient safety, medical errors | No Comments »

Common Errors of Pharmacy Technicians – Guest Post by Ashley Jones

Wednesday, June 2nd, 2010

Medications save lives, but they do so only when they’re taken correctly – by the right patient, who takes the right medicine, at the right time, in the right dosage, by the right route, and for the right amount of time. According to the National Patient Safety Foundation, of the 3 billion prescriptions that are filled, as many as 30 million dispensing errors occur. While some of them are not even noticed, others can have serious consequences, even resulting in death at times. The most common pharmacy errors occur when:

• Pharmacy technicians hand out the wrong prescriptions to patients – they get the names wrong, which means the entire set of medicines is wrong. (Pat was once given pills for another patient with the same last name. The technician did not ask for her first name.) And when patients fail to check the drugs they’ve been given and follow the prescription blindly without even looking at the name, it spells disaster in the making.
• Overworked and negligent pharmacy technicians give out the wrong drug because they don’t read the prescription carefully. This could cause serious consequences if the patient is allergic to the new drug or if it worsens their symptoms and causes them to become more ill.
• Pharmacists and technicians substitute one drug for another without checking with the doctor who prescribed the drug. This could lead to complications because the pharmacist is assuming that he/she is qualified to make the switch.
• They give out drugs that are past their expiration dates and which could either cause harm or not effect a cure since they are worthless past a certain date.
• Pat adds: They can misinterpret handwriting and fill the prescription with the wrong medication.

Errors can have profound consequences for the pharmacists who supervise technicians. A former Ohio pharmacist pled no contest to involuntary manslaughter of a 2-year-old child who died in 2006 as a result of a chemotherapy compounding error. The pharmacy board revoked the pharmacist’s license, and a grand jury indicted him on charges of reckless homicide and involuntary manslaughter. The pharmacist faced up to 5 years in prison. Prosecutors held the pharmacist responsible for the toddler’s death because he oversaw the preparation of her chemotherapy. The child had undergone surgeries and four rounds of chemotherapy to treat a curable malignant tumor at the base of her spine. She was supposed to receive her last dose of chemotherapy on the day of the error. A pharmacy technician mistakenly prepared the infusion using too much 23.4% sodium chloride. According to a news report, the technician mentioned to the pharmacist that the final preparation didn’t seem right, but the error went unnoticed. The infusion was administered to the child, who died 3 days later.

The Institute for Safe Medication Practices expressed the outrage of many in the patient safety world that this case resulted in criminal charges. Safety experts including ISMP advocate for a fair and just path for individuals involved in adverse events, arguing that punishment simply because the patient was harmed does not serve the public interest. Its potential impact on patient safety is enormous, sending the wrong message to healthcare professionals about the importance of reporting and analyzing errors.

Most of these errors occur when pharmacy technicians and pharmacists are too busy, distracted, and overworked. As patients, we can help minimize pharmacy errors by being vigilant, checking the name on the prescription, double checking the medicines against the prescription, ensuring that the drugs are not past their expiration date, and consulting the doctor before we switch to generic or branded equivalents. Don’t be in a rush because it could be a matter of life and death – take the time to check with your pharmacist if you’re not sure that you’ve been given the right medication or if it looks different from what you’ve been taking so far. It’s your health and your life, and unless you assume responsibility for both, you are equally to blame for the disasters that happen when pharmacy errors occur.

This article is contributed by Ashley M. Jones, who regularly writes on the subject of Pharmacy Technician Certification. She invites your questions, comments at her email address: ashleym.jones643@gmail.com.

What are these?

Tags: drug store errors, medication dispensing errors, Medication errors, pharmacy errors, pharmacy technician errors
Posted in Damages, Medication errors, Patient safety | 2 Comments »

6 Pieces of Good News For Nursing – and Patients by Pat Iyer

Wednesday, April 21st, 2010

In the January/February 2010 The American Nurse, a publication distributed to members of the American Nurses Association, President of the ANA, Rebecca Patton, shared reasons to be optimistic about nursing.

1. The growing focus on the nursing shortage and the steps towards healthcare reform have brought nursing to the fore in the minds of the nation.

2. President Obama shows exceptional concern for issues affecting nursing, as evidenced by his personal comments about the nursing faculty shortage, the overall nursing shortage, poor working conditions for nurses, and issues of low compensation. He shows an appreciation for the critical, unique role nurses perform.

3. Funding for nursing education has been increased by greater than 40 percent to a historic $243.9 million in the next budget cycle. An additional $200 million in funding was found in the stimulus package.

4. Several states are working to require nurses to have at least a bachelors of science in nursing on their 10-year anniversary of being an RN. Education matters in the safety and care of our patients. Research shows the impact of education on reducing medical errors and improving patient outcomes.

5. For the eighth consecutive year, nurses have been voted the most trusted profession in America, according to Gallup’s annual survey of professions. Eighty-three percent of Americans believe nurses’ honesty and ethical standards are either high or very high.

6. This month the standard for passing the nursing licensing test is higher. The National Council of State Boards of Nursing concluded that safe and effective entry-level RN practice requires a greater level of knowledge, skills, and abilities than was required in 2007. The passing standard was increased in response to changes in US healthcare delivery and nursing practice that have resulted in the greater acuity of clients seen by entry-level RNs.

What are these?

Tags: nursing education funding, nursing shortage
Posted in Nursing malpractice, Patient safety, medical errors | No Comments »

The real outcome of patient safety

Monday, April 19th, 2010

Reducing the number of preventable patient injuries in California hospitals from 2001 to 2005 was associated with a corresponding drop in malpractice claims against physicians, according to a study issued by the RAND Corporation.

Researchers studied both medical malpractice claims and adverse events such as post-surgical infections across California counties and found that changes in the frequency of adverse events were strongly correlated with corresponding changes in the volume of medical malpractice claims.

“These findings suggest that putting a greater focus on improving safety performance in health care settings could benefit medical providers as well as patients,” said Michael Greenberg, the study’s lead author and a behavioral scientist with RAND, a nonprofit research organization.

The link between safety performance among health care providers and malpractice suits has been of central interest to policymakers in the ongoing debate over health care reform. The RAND study is the first to demonstrate a link between improving performance on 20 well-established indicators of medical safety outcomes and lower medical malpractice claims.

Researchers analyzed information for approximately 365,000 adverse safety events, such as post-surgical problems and hospital-acquired infections, and for approximately 27,000 malpractice claims, all of which occurred during 2001-2005. The researchers found considerable variation among California’s counties, in both the frequency of adverse events and of malpractice claims.

Should a Nurse go to Prison for Reporting Concerns about a Physician? by Pat Iyer

Wednesday, February 17th, 2010

Transcript of the trial now available at this site: http://www.scribd.com/doc/30364402/Transcript-of-Mitchell-Bogus-Criminal-Trial

Anne Mitchell RN

Two West Texas nurses faced up to 10 years in prison and a fine of up to $10,000 for reporting concerns about the substandard care of Dr. Rolando Arafiles Jr. How did this happen? Nurse Vicki Galle and Nurse Anne Mitchell were part of the tiny staff of a tiny hospital in a tiny town in West Texas. Winkler County Memorial Hospital has 15 beds, employs 15 registered nurses and 17 licensed practical nurse, and has 7,000-8,000 people in the entire county. Both nurses worked at the hospital for over 20 years. Vicki and Anne reported concerns about Dr. Arafiles to the Texas Medical Board. They, as well as others, were concerned that his practices were inconsistent with the quality of care and patient safety. They were also concerned about his use of non-therapeutic treatments and prescriptions. The two nurses provided medical record numbers to the Board, but no patient names, to support their concerns.

When the physician was notified by the Texas Medical Board that he had been reported to the Board, he filed a complaint with the sheriff (who was one of his patients) alleging that he was being harassed. Sheriff Roberts tracked down the two nurses, who were indicted for misuse of official information and fired. The Texas Medical Board wrote a letter to the District and County Attorneys of Winkler County challenging the notion that the information provided to them was for nongovernmental purposes. They explained that the Board was exempt from HIPAA requirements and is a governmental agency.

Nevertheless, the case proceeded. Nurses throughout the country responded with an outpouring of support and dollars to build up the legal fund for the nurses. Patient advocacy, specifically reporting concerns about a practitioner’s standard of care, is protected under Texas laws and supported by the Nursing Code of Ethics. The case was seen as having the potential to affect the future of patient safety throughout the entire country.

The criminal case against Nurse Galle was dismissed on 2/1/2010, a week before trial was to start. But the case against Nurse Mitchell proceeded. The jury heard details of the cases of substandard care. During cross-examination, Dr. Arafiles struggled to define “standard of care”.

Doctor Rolando Arafiles said he supports the reporting process, but not in this case, because he felt Anne Mitchell was harassing him when she sent an anonymous complaint to the Texas Medical Board. The defense grilled the doctor about medical mistakes he made including one where he injected a needle into the bone of a patient and another where he sent a child with appendicitis home without treatment. The prosecution and defense agreed to nickname the instances on record in which Dr. Arafiles made medical mistakes. Those cases are being called, “Turkey Toe”, “Appendix Boy”, “Rubber Finger Tip”, and “Skin Graft”. “Rubber Finger Tip” references the instance when Dr. Arafiles sewed a part of a suturing kit onto a patient. It was a part of the kit not meant to be used on patients. During testimony, Dr. Arafiles said he meant to use it as a brace and accidentally sewed it to the patient.

During his cross-examination, Dr. Arafiles discussed the nutritional supplement called “Zrii” that he recommended to patients. The doctor admitted that Sheriff Roberts sold Zrii and even held meetings at the local Pizza Hut to recruit others to sell the product. According to the defense, the main ingredient in Zrii is white grape juice and it sells for around $40 a bottle.

At one point Dr. Arafiles was asked whether diabetic patients might have a tendency to heal worse than patients without diabetes. To the dismay of the audience, he said no, that there is no difference. The audience gasped, after which point Hon. Judge James Rex told the audience to keep quiet or else risk being thrown out of the courtroom.

It took the jury less than an hour to return a not guilty verdict on 2/11/2010. The jury foreman said the panel of six men and six women voted unanimously on the first ballot, and questioned why Nurse Mitchell had ever been arrested. “We just did not see the wrongdoing of sending the file numbers in, since she’s a nurse” said the foreman. After the verdict, the nurses’ lawyers quickly turned to the lawsuits they filed in federal court against the county, the hospital, and various officials, charging that the firings and indictments amounted to a violation of due process and their First Amendment rights. Nurse Mitchell’s lawyer said, “We are glad that this phase of this ordeal has ended and that Anne has been restored to her liberty, but there was great damage done in this case, and this does not make them whole.”

President of the American Nurses Association Rebecca Patton called the verdict “a resounding win on behalf of patient safety. The message the jury sent is clear: the freedom for nurses to report a physician’s unsafe medical practices is non-negotiable.”
Sources:
http://www.nytimes.com/2010/02/12/us/12nurses.html
http://www.texasnurses.org
cbs7news, Beau Berman

What are these?

Tags: Anne Mitchell RN, patient advocate, Rolando Arafiles MD, whistleblower, Winkler County
Posted in Communication skills, Medical malpractice, Patient safety | 1 Comment »

Medical-Legal Topics

Archive for the ‘Patient safety’ Category

Death after being restrained by Pat Iyer

When should nursing staff call a rapid response team? by Pat Iyer

Failure to rescue by Pat Iyer

Why don’t healthcare providers follow the rules? Part 2 by Pat Iyer

Why don’t healthcare providers follow the rules? Part 1 by Pat Iyer

Prescription drug overdoses on the rise in U.S.

Common Errors of Pharmacy Technicians – Guest Post by Ashley Jones

6 Pieces of Good News For Nursing – and Patients by Pat Iyer

The real outcome of patient safety

Should a Nurse go to Prison for Reporting Concerns about a Physician? by Pat Iyer

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