How to begin to improve patient safety

Dr. Ira Williams drirawilliams at GMAIL.COM
Wed Nov 12 13:49:38 UTC 2014

Dr. Bell, and Others,

My answer to How to do this well is the challenge? Begin by reading: Unaccountable, Dr. Mary Makary, 2012. His one word title captures what has always been missing within the medical profession. Next read Find The Black Box, my 3rd book on HC. I was compelled to write this book after reading Unaccountable. I OFFER A SOLUTION!

First, you might begin by reading several of my Open Letters on my web site. They end with little link references. Also at the bottom of that page is a 1938 Hollywood short movie (20 min.) That Mothers Might Live (Semmelweis). Oliver Wendell Holmes Sr. MD, was saying the same thing as Semmelweis, at the same time in America, (1840s) and he too was castigated and rejected by his, your profession.

Code of Silence dominates every hospital medical staff, and until meaningful medical peer review replaces Sue or Forget It as the system of choice for the review of questionable patient care doctors will continue to self-destroy their profession.

The first step in improving patient safety should be a process to describe in detail the current HC delivery system. That process will demonstrate that each state is responsible to create, and maintain an effective delivery system with clearly defined points of authority, and delegated authority necessary for effective accountability. Accountability is a by-product of authority or delegated authority.

The practice of medicine is a licensed privilege, and not a birthright. Every state medical examining board is over 100 years old, and each board’s mission statement includes the phrase “to regulate the practice of medicine”. How well has that worked out? State MEBs rarely, if ever, participate in patient safety conferences, etc. Strange!

I can provide a plan for a 21st century HC delivery system that would go far beyond anything previously imagined. But that plan is based upon recognition of each state’s responsibility to contribute.

I hope my comments are accepted in the manner they are intended, to broaden the debate, discussion on how to begin to create a far better HC delivery system.


Dr. Ira Williams
Author:  Find The Black Box
Prevent Needless Hospital Deaths & 
The Solution No One Else is Talking About.
drira at
Dr. Williams is available for speaking engagements.

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