National Health Insurance: Is it the answer to our healthcare problem?

The United States healthcare system is often criticized as being one of the most costly and ineffective systems in the developed world. Compared to countries with socialized healthcare, such as Canada and the United Kingdom, America spends a much higher percentage of their GDP on healthcare, yet there are still millions of people within its boundaries that have no health insurance and thus suffer from lack of proper care. The graph on the left shows us that as of 1999, 16% of our population was uninsured, and that number has not decreased. Because of all the criticism that our healthcare system has been receiving, healthcare reform has become one of the hot topics of this year. A type of national health insurance has been proposed by some as a possible answer to this healthcare crisis. This week, in response to this issue, I decided to search the blogosphere for post regarding national health insurance that would enlighten me on its pros and cons. I was successful in finding one post opposing socialized medicine and another that gave a more positive view of this plan. The first post, Top 10 Trends in Healthcare, was found in the blog entitled The Holistic Economy by Daryl Kulak. The author gives his readers of list of ten ways towards which America's healthcare is shifting. He includes trends such as: the continuous rise in cost of medicine, the tendency for companies to opt-out of providing health insurance for their employees, and the increase of consumer-driven healthcare, among many others. More important to this post is his view on the shift of the perception of socialized medicine of the American public. He believes that a "government-run system" would not work in the United States because we value our independence and our freedom of choice too much. While he does acknowledge the need for reform, he does not pose a better option for change. The second post, Most Doctors Want a National Health Plan, by Jane Sarasohn-Kahn, was found in the Healthcare Blog. She is more optimistic in her view of the possibility of implementation of a more socialized healthcare system in our country and supports her thoughts with a recent study claiming that more physicians desire universal coverage now than in 2002. Below you will find links to the comments I left on these authors' pages, as well as the actual comments themselves. I urge you to read their post and look at the comments they have accrued in order to better inform yourself on the realities of national health insurance.

Comment 1 - I have to admit that I found the ten points you provided in this post to be pretty accurate. In particular, I was intrigued by your comments on American's distrust of socialized medicine. Although you do admit that our healthcare system is in need of reform, you failed to mention a different alternative to national health care. I would have liked to see you go more in depth with this trend because it is an extremely important topic right now. I feel that if America thought that the answer to our healthcare crisis was in a socialized healthcare system, our fear of losing our independence would not overcome our desire to better this country. I am not implying that America should shift towards a national health insurance, but you seem to completely dismiss it as an alternative. While your experiences might have not been excellent with the socialized Canadian healthcare system, I am sure that you acknowledge that both the Canadian systems as well as the United Kingdom's system have some parts to it that work well and from which we could learn. It might not require a single payer system to repair our healthcare problem, but we must do something in order to help all those millions of people in our country who find themselves without insurance. While alternative medicine can help these people in the short run, there is going to come a point in time when they are going to need specialized care, and then it will be more costly on the country then if we are proactive now in changing our healthcare system into one that will be sustainable for a long time.

Comment 2 - In the case of a national health insurance, I would imagine that there would be fewer physicians that would be against it rather than for it. I can see why there would be an increase in physician supported in the group of ER doctors because you are right in saying that they do see most of the uninsured patients, but I have a hard time believing that other doctors would want this to happen. The reason for my previous statement is that if we were to function under a single payer system, much of the competition would die down and physicians would be paid a much lower salary than what they are currently earning. While I am neither for nor against a national health plan, I do have some concerns with the quality of care that would be provided by such a system. It is often the case that we focus on the good qualities of socialized healthcare networks in other surrounding areas, but very little do we notice all their flaws. Also, if we take a look at the current government run healthcare system, otherwise known as the VA, it is not the best of systems. In fact, there are constant stories in the news that remind us of the low quality of care that VA patients receive. I would hope that, if our country did move towards a more socialized healthcare, the appropriate measures and precautions be taken. I do think that there are parts of our healthcare system that do work, and that trying to fix what we already have would not be a bad idea either. In terms of the chart that you provided (pictured on the upper right), I would like more information about how the study was conducted. Were the doctors who were polled randomized? What types of questions were they asked? It just seems to me that six out of ten doctors is a bit extreme in terms on national health insurance support. If you could please direct me where I could view the study, I would greatly appreciate it.

Non Profit Hospitals: Are they becoming too focused on maximizing profits?

Within our healthcare system, there are
three types of hospitals which provide services for their surrounding communities. There are non-profit hospitals, for-profit hospitals, and government funded hospitals. The basic difference between these entities is that for profit hospitals strive to serve patients while still maximizing revenue for their shareholders, while non-profit hospitals are said to focus on providing charitable care to their community, and government funded hospitals also focus on serving the community through governmental funds. Through this network of facilities, most of the people within our country receive the proper care that they demand. While this system has worked well for many years, many non-profit hospitals are currently being scrutinized and accused of diverting from their main focus and instead making money more of a priority. If this were to be the case, this could potentially cause a plethora of problems because then these hospitals would be receiving tax breaks under the false pretense that their main focus is to serve the community rather than to make money.

There was a recent article posted in the Wall Street Journal that speaks about the recent trend in non profit hospitals in terms of revenues. As seen on the graph on the upper right, they show that hospitals have very drastically improved their net income, from $544 million dollars in 2001 to $4.27 billion dollars in 2006. They highlight the success of non profit hospitals such as Northwestern Memorial Hospital in Chicago, Cleveland Clinic, University of Pittsburg Medical Center, University of California at San Francisco Medical Center as well as a Catholic Healthcare West ( a system of hospitals in the San Francisco area). The authors point out that much of the income of these facilities has been dedicated to the renovation of their buildings, large payments to CEOs, and acquiring state of the art equipment, rather than on charitable care. While some of these expenses might seem somewhat deviated from the main purpose of serving those in need, I believe that we cannot be quick to judge all of these hospitals for spending the amount of money that they do in these areas without looking at the big picture. Non profit hospitals have always had to compete with for profit hospitals. As one of the writers for the Health Care Blog, Maggie Mahar (pictured left), stated in her blog post titled "Do non profit hospitals deserve their tax breaks?", non profit hospitals that are surrounded by a healthy mix of for profit hospitals are bound to act like for profit hospitals because they have to fight in the same market for the same patients. Although their main purpose is not to maximize income gains, money is necessary to run a hospital. It is no surprise that these hospitals mentioned above are paying money to renovate their facilities or to bring in state of the art equipment, because aesthetics and appearance of success is one of the ways in which hospitals can draw patients into their doors. While I am not condoning the focus of profit maximizing in non-profit hospitals, I am saying that perhaps a closer look at their total activity as a whole might be more beneficial and will give us a better understanding as to whether these hospitals are adhering to their primary mission of serving the community in need of care.

Because of all the fire that non profit hospitals have been receiving, the Internal Revenue Service has been very proactive in trying to investigate these cases and make sure all hospitals are complying with the community benefit standards that are required to qualify as a tax-exempt charity under section 501. Recently a study was done to show what the average activity was for most of the non profit hospitals in the United States. They were able to receive data from four hundred and eighty seven different non profit hospitals. I found it very interesting that the study found that these facilities were serving an average of 46 percent of people with insurance, 46 percent of people under government plans such as Medicaid and Medicare, and 7 percent with no insurance. I feel like these numbers really do show that on average, non profit hospitals really are helping a large part of the population who is in need. However, I do believe that Maggie does pose a good point when she say that perhaps the IRS should put a minimum requirement on charitable care in order for these non-profits to quality for tax exemptions, because at least we would then not doubt that they are providing at least a sufficient amount of help to the communities in need which they strive to serve. This would serve as a way to ensure that all of the money that our government spends on healthcare is being put to good use, and perhaps lead us into a future with a more efficient healthcare system.

Healthcare: Accessible?

Healthcare access is one of the major problems in our society. Although we have numerous resources, there are still thousands of people who do not receive proper care due to lack of information or lack of insurance. Unfortunately, many people are not aware of all the free and low price care that is available to those in need. This week, I decided to explore the web environment for healthcare access websites. This included websites that did research on healthcare access, provided healthcare plan quotes, or even provided information about providers around our areas. I came across ten websites which I found to beneficial for all my readers. Most of these sites exemplified the characteristics listed by the Webawards website for the category of healthcare.

My first step to finding information about healthcare access was to look for websites that specialize in this kind of research. The RAND Corporation website was a perfect place to start. The RAND Institute focus on policy analysis, and if one looks at the Healthcare for the Uninsured and Underinsured page, you will find various research projects on access for prison health, children's health and elderly health. The site is fairly easy to navigate and has links to the RAND Health page which provides research information on many health issues of today. The National Association for Healthcare Access Management also provides information on access, but it seems to be more beneficial for members than for the general population. Nevertheless, by having links to access reports on the right hand side, it does shed some light on the problem of healthcare access in its homepage. Two other websites that are also very easy to use and appealing to the eye are The National Conference of State Legislature Medicaid for the Uninsured page and the International Center for Equal Health Care Access pages. The first website gives information about healthcare for all 50 states of our country. The second one focuses on equal healthcare access for the world, and even tells you how to become a volunteer to help make this mission possible. Four other websites that I looked at now focus on actually giving you information on your options for healthcare plans, or on helping you self diagnose your any symptoms you may have. These websites are: eHealthinsurance, which with three easy clicks gives you health insurance quotes around your area, Healthcare.com, which facilitates the search for physicians and health facilities within your area, Kaiser Permanente Interactive Health Plan advisor, which helps you design the best plan for you within Kaiser (this website actually won a webby award), and VisualDXHealth, which allows you to input your symptoms into the website and it will give you a picture of what you might look like if you have the disease. The last two sites I looked at were more local. The LA Care Health Plan provides information for people who are uninsured and underrepresented on free clinics, low cost insurance, and options such as Medicaid and MediCal. The Los Angeles Free clinic website gives information to patients in need of assistance by letting them know that they can get healthcare, at no cost. It was very rewarding to see that there are some websites that care about the accessibility of healthcare, and I hope that my readers will find these sites helpful and will refer whoever is in need of more information to to these websites, because lack of knowledge should not stop anyone from receiving the proper healthcare.

Nurse Shortage: Retention is Key

Within any healthcare organization, there are many systems that work interdependently to provide the optimal quality of care for all patients who enter through their doors. While all of these systems are essential to these institutions, the nurse organization is one of the systems that is the most obviously necessary, and regrettably one that is currently depleting. Nurses are at the forefront of the delivery of care to patients, often being the ones who have the most contact with the patients thus influencing their opinion of the hospital. Because nurses provide mostly one on one care, it is vital that these organizations maintain the adequate number of qualified nurses to fulfill their patients’ needs. Unfortunately, we are currently facing a nurse shortage that seems to only have the potential to increase in the next ten years. Issues such as understaffing, low morale and high turnover are just some of the things affecting the nurse organization. In order to combat this shortage, healthcare organizations must put emphasis in nurse retention and education programs, so that they can continue to provide excellent quality of care with a sufficient amount of nurse aid.

An example of the dissatisfaction of the nursing organization can be seen in the upcoming ten-day strike, held by the nurses of Sutter Hospitals in San Francisco. According to the Mercury News, a local newspaper in the Silicon Valley, nurses from eleven different hospitals in the area reported that they will be on strike for ten days beginning March 21st. Some of the hospitals that will be affected are: Mills Peninsula, Sutter Delta and Eden Medical Center. Not only will these private hospitals have strikes, but the nurses at Contra Costa Regional Medical Center, along with nurses in county health clinics and jails, will also be holding a three day walkout beginning March 21. As demonstrated by the picture on the right, this is not the first time these nurses have united under one cause. In nine days, these women will rally up once more to fight the county official's decision to "freeze the county contribution for health benefits for current employees and retirees, thus causing the nurses to pay an increase in premiums beginning in 2009." Once this is put into place, new employees will receive a set amount of money for health insurance and will not receive health benefits upon their retirement. According to the county, the reason behind this cutback is the outstanding liability of $2.6 billion for retiree health benefits which was unfunded. Although nurses are aware of the lack of money, they are upset that they are the only county employees who are being cut back on benefits; all other non-union employees and managers are not being asked to take the same cut. Along with the request for better retirement health benefits, nurses are also asking for better meal and break relief , as well as safer lifting procedures.

While ten days may not seem like a long strike, this length of time without nurses is actually very costly to hospitals. According to Dr. Jeffrey Smith, and executive director for one of the affected hospitals, hiring registry nurses can cost around $1.5 million dollars per week. Not only do registry nurses cost more, but they also pose a higher threat to the patients. These traveling nurses are usually not familiar with any cases and they are not acquainted with the protocols, processes and mission of the institution. This makes them more of a liability that regular employee nurses. Instead of having to use all of that money to pay registry nurses, hospitals should reconsider what they proposed plan of action is, and negotiate with the California Nurses Association so that they can reach an agreement which will stop the nurses from going on strike. Hospitals need to realize that with the current nurse shortage problem, nurse retention is really what is going to help them meet California's New Nurse to Patient Law which requires one nurse per five patients in general floors, and much smaller ratios in more specialized floors.
According to the recent research of the American Association of Colleges of Nursing, there are approximately 116,000 registered nurse vacancies across the United States. This is equivalent to a vacancy rate of 8.1%. While this might not seem like a large number, this actual translates as approximately 800,000 vacant RN positions. If we were to look at the number of states that will have predicted shortages by the year 2020, all but five can be accounted for (US Department of Labor). California is by far one of the most affected states, with less than 600 registered nurses for every 100,000 people and its only projected to get worse. With such an increasing demand of nurses and a decrease in the supply, the quality of care is bound to decrease because of the lack of provider services. Many studies show that there is an increase in the hospital related mortality rate, in the failure to rescue rate, and in the length stay with lower numbers of nursing staff. Moreover, being overburden because of overstaffing does not allow the nurses to achieve the quality of care goals, such as patient centered care, decreased waste and anticipation of patient needs, established by the Institute of Medicine.

Though these figures are quite staggering, it is important to look at the underlying causes of the problem. One of the reasons for why we are noticing such a decline in the supply of nurses is because of the low enrollment rates in nursing schools. While there are a great deal of interested candidates every year, there are just not enough spots for all of the applicants. According to a recent study done by the U.S. Department of Health and Human Services, there are on average about 30 to 40 percent of qualified applicants who get turned away from nursing programs. The American Association of Colleges of Nursing equates that percentage to about 40, 285 applicants a year. This is a result of “insufficient number of faculty, clinical sites, classroom space, clinical preceptors and budget constraints”. Because there are fewer new nurses entering the workforce, the average age of the nurse is increasing. Currently, only 9.1 percent of nurses are less than 30 years of age, The AACN reports that in a current survey done of the nursing workforce, 55% of them said that they were planning on retiring between the years 2011 and 2020. As can be seen in the line graph on the right, not only are healthcare organizations going to lose their current nursing workforce, but demand is also going to increase because of the rise of the aging population. The baby boomer generation is going to be entering their sixties soon, and they are going to require an increased amount of care in the near future.

While the lack of a new nurse workforce is a great concern for all, a more pressing issue lies in the high turnover rate of nurses found within healthcare organizations. This high turnover rate is fueled by understaffing, giving too much responsibility too soon to new RNs, weak orientation programs, decision making by supervisors without input by those most familiar, and nurses not receiving positive feedback from supervisors. These types of issues should not be arising in a time in which nurse retention is really key in maintaining a steady nurse workforce. Considering one of the key ways for retention is worker satisfaction, hospitals such as the Sutter hospitals should reevaluate their treatment of their nurses, because clearly there is no worker satisfaction if they are driven to go on strike. They should really internalize the idea that nurses are one of the most valuable resources they have, and without them, they will not function.

Looking for the Best: Finding Healthcare Information on the Web

For my post this week, I decided to go into the diverse world of the web and try to find informational websites on healthcare. Because of the nature of my field, my focus was mainly on websites that touch upon the topics of healthcare access and quality of care. While I did try and look for websites that looked at urban healthcare, I was only successful in finding one that really had substance. The first website that I came across was the U.S. Department of Health & Human Services website. I began to look in this site because this department is responsible for the issues of healthcare within our country, so I had high hopes for this website. I was not disillusioned. This page was probably the most helpful in terms of linking me to other very helpful resources. It also provided excellent information on policies and regulations, specific populations, grants and funding and so much more. Not only did this site have a plethora of information, it is also designed for very easy navigation. From this page I was able to go to the Agency for Healthcare Research and Quality website. They also are very informative in areas of evidence-based medicine, effective medicine and consumer and patient issues. Within their site, they also provided links to quality report cards, which can allow patients to look at how the clinic or hospital which they are part of ranked among others in areas such as safety and surgeries. Another place where I also was able to obtain quality research data was in National Institute of Health site but it was much harder to find. From the ten sites I found, the one that was the most informative on urban healthcare was by the Urban Institute. It gives information on Community healthcare, medicaid and medicare, long term care, and insurance among other topics. It very clearly shows the links for these issues making it user friendly. Also, it provides a list of publications on healthcare issues as well as links to policy centers which I found very helpful. In general, I believe my search to have been extremely productive and hope that readers will use the links I have provided in my linkroll to become more informed in issues in healthcare, and thus make better decisions about their care.

Evidence-Based Medicine: A Way to Decrease Waste

Efficiency and effectiveness are both qualities that all healthcare organizations should always strive for. This week, I decided to look into the blogosphere for ways in which these two qualities can be achieved. I was able to come across a couple of blogs that really inspired me. They both touch upon the importance of evidence-based medicine in reducing the amount of money wasted each year, thus improving both efficiency and effectiveness. It is quite often that we hear that the United States is one of the countries that spends the largest percentage of GDP in healthcare, yet there are always complaints about the quality not being up to par. This can be partly attributed to the amount of money wasted each year on unnecessary procedures that have no real effect on the patient's health.

The first blog I explored is called The Healthcare Blog. I specifically read a post by Maggie Mahar entitled A Blueprint for Healthcare Reform. In this post she argues that "unnecessary care doesn't just waste dollars: it can be hazardous to your health". Because of this, she stresses the idea that reduced utilization can lead to better outcomes, and supports this through the findings of Dr. John Wennberg. The other post I looked at showed a different side of the problem of evidence-based medicine: the lack of it in the United States. In a blog named Gooznews.com, Merril Goozner wrote a post titled FDA Proposes Lack-of- Evidence Based Medicine Policy. He explained that the FDA is trying to get a policy passed which would allow pharmaceutical companies to give journal articles advertising the off-label uses of the specific medicines to physicians. This would of course incentivize more studies for the other uses of the medicine, but unfortunately it would not be in a controlled and supervised manner and findings from these trials can lead to misleading information regarding the true benefit of the medicine for the off-label use. Through his article, he is able to convey the inefficiency of this policy, and the harmful effects it could have on our healthcare system.

I have attached the comments I made in regards to their arguments, and hope that you will take the time to read what these authors have to say to better understand the need for evidence-based medicine.

Comment 1 - First and foremost, I would like to thank you for this very insightful post. I myself had never read or heard any of Dr. Wennberg's work, and find it very intriguing that knowledge in this subject has been so prominent yet no one has seemed to be doing much to fix the problem of waste in our healthcare system until very recently. I would have to agree with much of what was written in the previous comments in terms of why so much money is being disposed of so carelessly. Both the fear of malpractice law suits as well as the lack of flowing knowledge between patient and physician can often lead to overusing treatments and procedures. I think that because of this it is very important that we do keep in mind this idea of evidence-based medicine, and really focus on the patient's actual needs. I found the concept of "Manifest Efficacy" to be really relevant to this issue as well. Although I had never heard the actual term, the concept of it is one that is very familiar. I think that it is very much the responsibility of the physician to be looking out for their patients because most of these people are not very knowlegdeable of what many procedures entail and thus trust their caregivers wholeheartedly, never really questioning what is being done to them, instead believing that it is what is best for their health. I believe that in order to move into a more patient based healthcare system, new ideologies that promote this type of environment need to be accepted by Healthcare organizations. An excellent example of this can be seen in the new rules established by the Institute for Healthcare Improvement. These rules re-define the way HCO's manage healthcare, and really do a great job at trying to cut down some of the waste. Some of these rules include 1) Treating health as a continuous process 2) Letting knowledge flow freely between caregiver and patient 3) Customizing Care 4) Letting the patient be the source of control and decision-making, and so forth. By living up to these types of expectations, there is a shift in the mentality of how to access the necessary care for each individual, and thus a better quality of care is provided.

In regards to the rewarding quality rather than quantity, I believe that the gradual shift towards a pay-for performance method of reimbursement might provide the necessary incentives for providing better quality of care. While this might not be the only answer, it might serve as a stepping stone for future change.

Comment 2 - Merrill, thanks so much for giving insight on this new policy that is trying to be enacted. As a policy major, I am appalled at the idea of a policy such as this one even being brought to the table. I cannot believe that anyone would really think that this would be beneficial for either physicians or patients. Not only does this pose a possible threat to patients, but it could potentially be more costly for physicians and even the pharmaceutical companies if these drugs prove to have adverse effects when using them for off-label purposes. I am curious to know if the people who would be put in these so-called clinical investigations are aware of what they are putting themselves through. Even if they did, you are correct in saying that the result of these studies could be misconstrued. Who can assure us that the proved benefits of taking a medicine are not the result of another confounding factor. It makes me very weary of where the FDA's heart really is if they are willing to propose something that could potential even take someone's life. While pharmaceutical companies might make more money rapidly, the long term effects and cost for the country cannot be measured. It is imperative that we keep the same type of test and trials that we have been doing in order to ensure knowledge of the true benefits of these drugs. I would hate to see so much money go to waste trying to recover from such a crisis that a policy like this poses.

Quaid Twins: Eye Openers to the Reality of Medical Errors

In late November 2007, the eyes of America were open to the reality of the threat of medical errors with the unfortunate experience of the Quaid twins. Dennis Quaid and his wife (pictured on the left) had put their two week old babies under the care of the staff of the Cedar Sinai Hospital, one of the most renowned hospitals in California. Little did they know that during the twins time at the hospital, they were going to be put under more danger than what they were admitted for. During one of the night shifts, the twins were administer a dosage of a blood thinner, Heparin, that was 1000 times what they needed. This put both twins into shock and they had to be transferred to the neonatal intensive care unit. There was another patient who also suffered the same problem, but their name was not disclosed. Fortunately, all three patients recovered from this medication error, and there are no signs of permanent damage. While the Quaid twins were able to survive this error, there have been other patients who have died from overdoses of Heparin. Though the Quaids are attributing this error to the pharmaceutical concepts, we must also considering the error in the delivery process administer by the hospital. It is the hospitals responsibility to ensure quality care to each patients, and thus should constantly be evaluating their performance so that errors such as these do not occur.

Even in a hospital as supreme in quality as Cedar Sinai Hospital, it is now evident that errors occur. In fact, according to the US Food and Drug Administration, 98,000 deaths a year can be accounted to medical errors. While the Quaid's are attributing this particular error to the pharmaceutical companies, it makes us wonder if there was anything the hospital could have done to prevent this error as well. Now a days, hospitals need to really begin to look at these problems internally and see what they can do to limit their liabilities without spending a surplus of money to prevent errors. For example, in the case of this overdose, perhaps if the person stocking the medicine realized that these two concentrations of the drug resembled each other, he or she could have made a sign to signal which vial was which, which would have probably been more cost efficient then they multiple days spent in the NICU and medicine to reverse the effects of Heparin.

If we look at the most frequent types of medication errors found within our hospitals, we can see that omission of a dosage is the most frequent. The bar graph on the right, provided by The Commonwealth Fund, a foundation which works to improve high performance in our health system, shows other causes as well. Improper dosage and prescription error are right below omission in frequency. All of these errors could potentially be solved, or at least reduced, by improving the systems performance of the hospital. Because more and more hospitals are realizing this concept, hospitals are moving towards a more factory based approach to reduce the number of mistakes within their practices.

One of the ways by which they are experimenting is by the use of the Six Sigma efforts, provided by General Electric. According to the Six Sigma Website, Six Sigma is a "measure of quality that strives near perfection". There are two processes by which this statistical measure can be achieved. One is called Six sigma DMAIC, which stands for define, measure, analyze, improve and control. The other one is Six Sigma DMADV which stands for define, measure, analyze, deign, and verify. Both of these methods try and achieve as little variation as possible.Through the use of these data based methodological process, companies can asses the efficiency and quality of their process, and install measure to constantly be improving and trying to achieve that Six Sigma, which would represent perfection. Many hospitals all across America are using programs such as this already. One of the hospitals that has seen results from the Six Sigma Efforts is St. Joseph Health Center in St.Louis. After implementing these processes, they were able to obtain a decrease in annual turnover as well as an increase in revenue and in emergency room admissions. By examining each part of their departments and really striving for the best, they have been able to radically turn around their hospital.

It is imperative that more hospitals look at constantly improving their system process to minimize the number of error that occur within their facilities. As hospitals, one of the main responsibilities and missions should be to save lives, not to endanger them. Errors such as the overdose of the Quaid twins are preventable and should be foreseen and accounted for. Only then will hospitals truly decrease their liabilities and become the health sanctuaries that we desire them to be.