Reduce medical malpractice and create a culture of patient safety

When I was a resident in internal medicine many years ago,  I saw an elderly woman who came to the ER complaining of chest pain and shortness of breath.  She had a history of heart disease.  When I listened to her chest, the crackles I heard emanating from her wet lungs told me she had congestive heart failure.  I treated her chest pain and gave her diuretics to help her get rid of the water that was making her drown in her own bodily fluids.  After an hour or two of treatment, she felt better.  I decided to send her home.

But as I did, a little voice in the back of my head told me that was a bad idea.

A few hours later, it was time for me to go home.  Call it a premonition or a sick feeling, but on my way out the door, I passed through the ER.  “Do you remember that patient you sent home,” a nurse asked me.

Do you remember’ are the three worst words a physician ever hears.  That’s because the triplet is usually followed by an update that the patient is doing poorly.  And so she was.  The patient I had sent home had returned near death.  Despite heroic efforts, she could not be saved.

I remember her name like it happened yesterday.  A wise colleague once told me “you never forget the names of those who die.”

Ever since that day, I’ve been a student of medical malpractice.

In 1999, the US-based Institute of Medicine (IOM) published a seminal report entitled ‘To Err is Human’.  In it, the IOM said between 44,000 and 98,000 Americans die each year of preventable medical errors.  According to the Canadian Adverse Events Study, as many as nearly 24,000 Canadians die in hospital of preventable medical errors.

If you do the math, as many people die in Canada every few days from preventable medical errors as die in commercial plane crashes.  When a plane drops from the sky, it makes headlines.  Not so, when it’s one patient who dies.

Complexity of modern health care.  These days, patients live longer.  By the time I see them, it means they are older and often have four or five major illnesses.  That increases the potential that treating one condition makes the others worse.  More and more patients are on experimental treatments that are frankly beyond the ken of your average frontline doctor or nurse.

Speed kills.  Twenty years ago, we saw 70-80 patients a day in my ER.  Today, it’s more like 130-140.  The faster I work, the less time I have to entertain that still, small voice in my head that tells me whether to send my patient home or admit her.

Pardon my interruption.  All of us know what it’s like to be interrupted while working on a task at work.  Medicine is no exception.  If anything, it’s worse because each interruption tends to be entertained because it’s assumed that if the interruption is about a patient, then it must be important.  But health care professionals aren’t any better than the rest of us at handing them.  In the ER, if I’m interrupted once while asking you about why you’ve come to hospital, I can usually get back on track.  Two interruptions, and it gets dodgier.  Three interruptions, and I probably won’t take a proper history from that point onward.

Forgetting the simple stuff.  Many preventable errors in hospital have to do with infection control.  Health care professionals continue to fail to wash hands before and after every patient contact.

Medication errors.  A disproportionate number of preventable medical errors involve medications.  These include the wrong drug, the wrong dosage, and even drugs given to patients with known allergies.  Some of these are the result of human error; others have to do with a system that until recently was not designed to detect and root them out.  In some cases, the wrong drug is given because the name sounds too much like another drug.  In other cases, two dissimilar drugs (one benign and the other dangerous) are contained in nearly identical vials.

Forgive me, I’m human.  We tend to forget that health care is an art, not a science.  We expect that there’s a right answer for every set of clinical circumstances.  Often, we’re making a best guess based on incomplete information.  We also tend to forget that health care is practiced by human beings, not robots or computers.  When arriving at a diagnosis or course of treatment, we may forget to ask a pertinent question or fail to take a pertinent detail into account.  Unfortunately, we have a long-rooted culture in health care of feeling unhealthy shame about medical mistakes.  In my opinion, that unhealthy shame makes it difficult for people like me to talk about our mistakes and difficult for people like me to listen to the mistakes of others.

I think looking at medical errors and creating a culture of patient safety in health care should jump to the top of the priority list.  That’s why I wrote about mistakes I’ve made in my book, The Night Shift – Real Life in the Heart of the ER, and it’s why I’m not afraid to talk about them on my radio show and with my colleagues.

I think all of us who work inside medicine’s sliding doors will feel better about ourselves and will help create a culture of safety if we do the same.

Do I remember?

Every day.

Adapted from a blog post that appeared on White Coat, Black Art.

Brian Goldman is an emergency physician and author of The Night Shift: Real Life In The Heart of The E.R., published by HarperCollins.

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  • skeptikus

    “Culture of safety” Ugh. It reminds me of Goering’s comment that everytime he hears the word “culture” he reaches for his gun.

    We don’t need a culture of safety. We need a culture of accountability. Doctors must pay for their errors, either in malpractice or, preferably, decreased reimbursements from quality conscious third-payers or, ideally, consumers themselves.

    The incentives that run the world: self-interest work in medicine too.

    • http://EmrgncyMD@att.net George Hossfeld MD

      Please don’t quote that IOM report. It has been quoted countless times by people who never stop and think. If that report is right, medical error is the leading cause of death in the US and you would have to be a fool to go near a hospital. That ridiculous report used 2 small retrospective chart reviews, 10 and 14 years old at that time, that tried to identify any “medical error” (a missed does of antibiotics, benadryl 25 mg instead of 50 mg) in charts of patients who died. They then made the quantum leap to suggest that the two were related! In addition, they extrapolated to the entire US population! Helped those IOM authors in their careers. Screwed every other doctor who has to hear it as if it were fact.

  • Killroy71

    Thank you, Dr. Goldman, for talking about this. We need a culture in which doctors and other medical professionals can admit and learn from mistakes, not all of which result of the kind of negligence that calls for lawsuits. If you all clam up, you can’t learn, as the past decade has shown, with the IOM update saying there’s been no material change.

    Tops on my list: implement a surgical checklist. It’s working in Michigan and elsewhere, why are surgeons so resistant? Also, when a pharmacist is added to the medical review team, there are fewer medication errors. They know more about the actual medicine than the “medicine men”.

    I know y’all are resistent to practice standards and EBM as “cookbook” medicine, so just write the book yourselves already.

  • http://www.drjshousecalls.blogspot.com Dr. Mary Johnson

    What Skepticus said.

    But (big but) I think he’s leaving out a HUGE part of the equation – as NO ONE is looking over the shoulders of the suits & lawyers whose self-interested actions now drive so much of what doctors do.

    I’ve been waiting twelve years for accountability . . . for a couple a of small-town “non-profit” bad apples (and their lawyers) to pay for their errors.

    But accountability & transparency are illusions – even after “reform”.

    A very old friend of mine (who works in D.C. for a very prestigious government instiution) and I reconnected last week when he was in town for the high-school reunion I did not attend. As we talked about my horrific hometown experience in public service (which involved me intervening to stop – then blowing the whistle on – malpractice), he shook his head and said: “Mary, I could have told you that it would do no good to write anyone at DHHS and ask them for help . . . those at the top do not want to hear that something doesn’t work . . . they DO NOT want to know.”

    “You were not telling them what they wanted to hear, so you were a nobody.”

    That pesky self-interest again.

  • Finn

    If self-interest worked that well, no one in this country would be obese, no one would smoke, everyone would wear seat belts in cars, every patient would be adherent to treatment, and we’d all get at least 30 minutes of exercise at least 5 days a week. Obviously, self-interest is nowhere near enough incentive in and of itself to change habitual behavior.

  • igloodoc

    Another factor to be considered … did the patient meet Medicare admission criteria. Retrospectively, yes. Prospectively, maybe… (not enough info to tell)

    If she didn’t, you have to send her home (despite the objections of your “little voice”), and you end up owning the lawsuit. Welcome to the role of sin-eater… we get to eat the sins of those who make decisions and forsake responsibility.

    • http://thedocsquawk.com thedocsquawk

      Goldman is practicing in Canada, where there is no Medicare admission criteria.

  • http://www.meyersmedmal.com Jivanmeyers

    The anger and denial reflected by some of the above comments demonstrates the extent of the challenge which lies ahead. before dangerous practices can’t be corrected there must first be an admission that they exist. Goldman candidly confesses error and shares with his colleagues and the public at large, his mistakes. Similarly, Peter Pronovost has written and advocated the need for doctors to be introspective and open. His work at Johns Hopkins Medical Center is reflective of his efforts to establish a culture of medical safety there. The introduction of a checklist at Hopkins, related to the placement the central lines, nearly eliminated post line placement infection.

  • http://www.BocaConciergeDoc.com Steven Reznick MD FACP

    We go into medicine to help people. Nobody wants to hurt or injure anyone. Medical Malpractice and trials are simply too expensive for physicians, hospitals and the public to afford. We need accountablity but it needs to be in the form of a plane crash or train crash type investigation by a NTSB type panel. We need an investigation of each poor outcome to determine why it occurred. Is it physician error? system error ? chance? The investigation panel should have the power to discipline the physician or health system based on their findings and make specific recommendations. Maybe the physician needs re- training? Maybe the physician needs supervision on those types of cases? Maybe the physician needs to be suspended or lose the license to practice. As for compensation, it needs to be in a Worker Compensation format based on age of the patient, cost of medical care , lost wages etc. I have been told that if one dies in a commercial airline crash federal law limits the payment to families to $25,000 per individual because that is all the industry can afford. If that is true why isnt the same philosophy applied to bad outcomes in medicine?

    • Matt

      Your information about plane crashes is wrong. There are some limits related to international travel, but they are not as low as you suspect.

      Really, though, given that the number of medical errors leading to damages is far, far greater than the number of paid claims, if it were easier to make claims it would likely be far more costly than it currently is.

      Also, you’d have the health insurers battling it as they’d lose their rights of subrogation.

  • Dr. J

    Okay, I’ll play the contrarian…
    If you are a doctor, and thinking, wow I should really disclose medical errors so that the systems at my hospital can improve and we can take care of patients more safely let me give you some advice; Don’t throw yourself under the bus just yet.

    In my emergency dept. I am sometimes asked to investigate errors and complaints and oversee a resolution process. As part of that I talk with patients or their families about what they think would be a reasonable outcome to their complaint or error. About half the time all the person really wants is an apology, about a quarter of the time they want to make sure the problem never happens again, and the remaining quarter want the nurse or doctor involved to loose their job or license, that’s the only thing they feel will be an appropriate outcome. The official licensing body of the area I work in also gets a copy of all reports after the process is complete.

    At this point the process is not totally about QA/QI, and does retain a punitive function. As a doctor with a mortgage and a family I understand why so many doctors are reluctant to participate in the process, this really is a job where a single error could cost you your livelihood if approached incorrectly.

  • http://www.drjshousecalls.blogspot.com Dr. Mary Johnson

    Dr. J, take it from this Dr. J, if you report medical badness, you might as well throw yourself, your family and every dream you ever had under the bus. I’m twelve years into a personal/professional nightmare because I did just that – and, even after five years in this blogosphere I’ve not gotten ONE BIT of substantive help from anyone in a position of oversight or “advocacy” – and that would include the fourth estate (journalists).

    From the Medical Board to the Medical Societies to JCAHO to DHHS to the US & NC AG’s to the AMA, everyone is brain-dead and prefers to dive under desks.

    There’s a whole lotta shooting of messengers going on – mostly by hospitals that want to cover stuff up – but at the same time look like they’re all about QA. And the malpractice lawyers on these boards don’t want you to know about that . . . because we “dime-a-dozen” doctors bleeding all over the place are all supposed to be “greedy” and self-interested . . . very basic self-preservation be damned.

    If medical Peer Review actually worked the way it’s supposed to – and fixing things was REALLY about fixing things – as oppose to being uber-punitive and satisfying the blood-lust of that one-quarter of “customers” who are out for revenge and nothing else (no matter if they’re right or wrong), we wouldn’t have a good portion of these problems to start with. But peer review has become a weapon of retribution and retaliation and a way to keep physicians quiet.

    • joe

      Dr Hossfeld brings up a good point. The 1999 IOM was based on data going back to the early-mid 1980′s specifically for New York State. Though these numbers have been debated in medicine the lay press and increasing MD’s (as seen by Dr Goldman above) have taken these numbers as gospel. This study made Lucien Leape’s academic career. I don’t expect the lawyers (Meyers and Matt) to read these studies critically. However, I DO expect the MD’s in the audience to read these studies critically. One of the authors of the original IOM article brought up flaws in his own study which if interested you can read. Also I have referenced a JAMA study below from 2001 that brings up the issue of reviewer bias. Of interest I have never seen this article quoted in the lay press and certainly not by the lawyers in the audience. I am not saying the IOM study is “wrong”. I am saying there were flaws in the study that nobody here actually appears to have understood.

      JAMA. 2001 Jul 25;286(4):415-20.
      “Estimating hospital deaths due to medical errors: preventability is in the eye of the reviewer.
      Hayward RA, Hofer TP.”

  • imdoc

    Matt:
    “given that the number of medical errors leading to damages is far, far greater than the number of paid claims, if it were easier to make claims it would likely be far more costly than it currently is.”

    This directly contradicts your other postings about costs of malpractice insurance and tort reform. That aside, it would seem you do not think an enterprise liability system like the airlines or other industries have would work. Medicine is one of the few fields in which one can be directly employed and be required to personally bear all the liability for acts related to the work.

    • Matt

      What other postings do you believe it contradicts?

      “Medicine is one of the few fields in which one can be directly employed and be required to personally bear all the liability for acts related to the work.”

      That’s actually not true. You’re personally liable for your acts if you are a truck driver, a fast food worker, architect, etc. But under the law, your employer is also typically liable for acts you commit in the course and scope of your employment. So typically, the employer’s insurer defends and pays the claim on behalf of both. In a professional situation you may have your own insurance, as well, though. You may be thinking otherwise because so many physicians are independent contractors – but that’s a distinction from the employer-employee relationship.

  • Tad

    I know all about this subject, my parent just died as a result of Malpractice……but suing is practically impossible because of Tort Reform in this State. If anyone cares to learn the facts concerning Malpractice, they should read the “Medical Malpractice Myth” by Professor Tom Baker. There is a great deal more Medical Malpractice than actual Lawsuits.

    Part of the problem is what Doctors learn….so called “Evidence based Medicine” is anything but. An eye opening article in the current November issue of Discover Magazine (Reckless Medicine) documents that “less than half the surgeries, drugs, and tests that Doctors recommend are proven effective”….in other words there is NO real Science behind them…..which in large part is a symptom of another Big problem that was covered very effectively by the former Editor-in-Chief of the New England Journal of Medicine, Dr. Jerome Kassirer MD, in his book….”On the Take, How Medicine’s complicity with Big Business can endanger your health”.
    I’ve had a lot of anger about what happened to my loved one, but I’m not here to bust on anyone, just to share some knowledge. If anyone would like a PDF of the November issue of Discover, e-mail me at TadResearcher@Gmail.com and I’ll e-mail you a copy.

  • http://www.meyersmedmal.com Jivanmeyers

    Those who feel that a candid disclosure to a patient or family members concerning the true cause of a preventable injury is tantamount to throwing oneself under a bus, I offer the following comparison.

    Imagine instead that “Dr. J.”struck and killed a pedestrian in a crosswalk while driving home from a long day at the hospital. Should Dr. “J” tell the surviving family and the police the truth. What if there are no witnesses to the tragedy other than Dr. J. isn’t telling the truth tantamount to throwing oneself under the bus. While the Constitution protects us from forced confessions in in matters involving criminal penalty, there is no right against self incrimination in civil matters. it is simply a matter of conscience.

    As to the actual number of fatalities due to medical malpractice annually, does anyone really think the actual number is important. Would 10,000 preventable deaths mean nothing needs to be done. And remember the IOM report was not evaluating the magnitude and frequency of harms other than death.

    “First, do no harm!” So long as the culture of medicine ignores the least of us, focusing instead on keeping terrible secrets kept to avoid entirely undeserved shame, medicine will not regain its soul. Doctors have no reason to feel shame because they made a mistake however serious the outcome. They should focus instead on offering comfort and support to those who suffer the consequences of the mistake and by sharing candidly the causes make less likely a repetition of the tragedy.

    • Dr. J

      I like your crosswalk example, but lets make it a little more complex. Lets say that you run someone over at a crosswalk but the lights at the crosswalk didn’t come on, and that the accelerator in the car seemed stuck (doctors like toyotas!), are you responsible for the accident (you were driving), is the car company (they made the faulty accelerator), Is the city (they didn’t maintain the lights at the crosswalk). The most human reaction to immediately admit fault, and the truth is that you did run the person over.
      What I am suggesting is that in the medical corollary to this situation there are many parts to the error. Since the future of the physician is sometimes at stake, they may loose their livelihood, they may want to consult Matt (or another lawyer) before admitting the ‘truth’ of their error.

      I agree with you that the focus in error should be identifying and remediating causal factors, but the current reality is that much of the focus remains on punishment of error rather than QI.

    • joe

      Mr Meyers:
      I think you actually have to READ the 1999 IOM report and and Dr Leape’s f/u reports before critiquing what it says, as clearly you have not. One of Dr Leape’s main points is the majority of the time the problem is not one doc committing malpractice rather a systems error at multiple levels. Frankly, your crosswalk analogy is meaningless in the majority of med errors. That doesn’t make a systems error “OK”, but it does mean the answer is a lot more complex that the soundbites you use. For example, many of us in the business know a real help would be one nationwide electronic medical record system which would minimize errors, ease evaluating medical records, and minimize duplication of services. That will never happen, partially because civil rights advocates (lawyers) have argued long and hard about the possibility of infringements on a patients record and partially because congress has been paid off by different software vendors who will reap billions. In the end we will have hundreds of systems that don’t talk with one another at the costs of billins of dollars, and still have the same problem. I suggest you actually read Dr Leape’s reports also the JAMA reference I listed.

  • jsmith

    Errors are inevitable in medicine ( as in other complex human activities) and will probably increase in number and severity as the population ages and gets more medical care. I am skeptical about the culture of safety to change this much. I am very skeptical about a culture of accountability to change this much. Sure, we can focus on some types of error and decrease their incidence, but then of the types of error that we are not focusing on will increase. This is simply how the world works.
    At bottom, the amount and complexity of medical care that is provided now and will be provided in the future rules out a very low rate of errors. Societies with unrealistic expectations are bound to be disappointed.

    • Matt

      Why do you think society has an unrealistic expectation?

  • http://www.drjshousecalls.blogspot.com Dr. Mary Johnson

    Jivanmeyers, I would submit that it is very EASY to jump up and down and yell “First do no harm . . . First do no harm!”.

    But again, you’re talking to a physician who believed in just that . . . and put a patient first in order to STOP malpractice . . . and, for her trouble, had her life & practice in her own hometown DESTROYED – by a “non-profit” no less.

    I still practice. But I’ve suffered horrible personal and professional losses – and I’ve most certainly not recovered from what happened . . . while those who worked the dark magic have walked away free-as-birds . . . with raises.

    NO ONE . . . particularly NOT ANY of the state & Federal & hospital oversight agencies – or advocacy organizations out there that preach about “cultures of safety” or “accountability” or “transparency” was there to catch me when I was pushed.

    A lot of people in this blogosphere “empathize”. But what have they done to help?

    I’ve been begging for help in this ether for five years – with things that the law can STILL address – FOR TWELVE YEARS.

    THIS IS REALITY. And too many people are determinedly looking away.

    The bus ran over me. Backed over me. And then ran & backed over me several more times. If this country (and all of the lawyers and journalists in it) want physicians to blow the whistle and report badness – then it is going to have to DO SOMETHING to PROTECT them when they do.

    And it did not happen with “reform”.

    • http://www.meyersmedmal.com Jivanmeyers

      Dr. Johnson, I gather from your remarks that you have suffered considerably as a consequence of following your conscience. In Pennsylvania and in many other states there are many protections offered physicians who report upon a colleague’s misconduct. Here you would have to be proven wrong about your criticism and your adversary would have to prove as well that you were motivated by malice.

      It’s ironic that the only remedy available to patients who have been needlessly injured is provided by a lawyer’s. I think it’s stranger still that lawyers are seen as the enemy of the health system and that their limited ability to provide for the victims of malpractice is under constant attack legislatively.

      • http://www.drjshousecalls.blogspot.com Dr. Mary Johnson

        I have suffered “consderably” and unfortunately I don’t live in Pennsylvania.

        FYI, I was motivated by the blue-from-the-chest-down-on-the-verge-of-total-respiratory-failure newborn suffering from pulmonary hypertension resulting from untreated meconium aspiration – as opposed to a misdiagnosed pneumothorax. There’s ZERO question about who was right and who was wrong.

        But I got fired, and the MD who screwed up (and who I will freely admit that I did want to throttle at the time) was eventually promoted to Chief of Staff.

        The baby survived without sequelae. I get a Christmas card from her grateful parents every year.

        Very nice. But because of the medico-legal void I fell into, I never got to have kids of my own. And I would have liked to have had kids of my own.

        So my question to you is, HOW MUCH do you want doctors to BLEED?

        Also unfortunately, Federal healthcare “reform” happened without addressing ANY of the problems common to medical peer review as it is currently practiced . . . and without standardizing protections for medical whistle-blowers . . .

        . . . for which I am the poster-child in North Carolina. You probably remember our most famous lawyer, former Senator/ex-malpractice lawyer, John Edwards. I PLEADED for his assistance while he was in office (all the while pontification about how much he “cared” about healthcare reform) – I might as well have been talking to a stone wall.

        OBTW, when lawyers are involved in anything, “proving” that you were in the right can be very expensive for physicians . . . whether or not they are fired/sued/libeled for whistle-blowing . . . or sued for malpractice.

        Something has got to give. It would be nice if our physician advocacy organizations started listening to these stories-of-woe (mine is most certainly not the only one) . . . and started doing something other than pretending these things do not happen.

  • http://www.BocaConciergeDoc.com Steven Reznick MD FACP

    In most states there is a Board of Medicine that receives reports of all bad outcomes in hospitals and adverse events by law. Patients can make a formal complaint to a Board of Medicine or to a county or state medical society. This triggers an investigation with consequences for the physician or facility if harm was done. If in fact a civil suit is filed against a doctor or facility the Board of Medicine is informed by law and investigates the incident as well. Physicians can suffer double jeapardy and the double expense of defending a med mal case and then defending your license to the state medical board even if the case is settled out of trial for a minimal amount because it is a frivilous suit.

  • http://www.drjshousecalls.blogspot.com Dr. Mary Johnson

    I’m just too tired to rework this comment tonight.

    Dr. Reznick, I hail from North Carolina – a state whose Medical Board fancies itself very “progressive” and “transparent” and “effective” in policing bad doctors.

    As a medical whistle-blower, I have twelve years under my belt to prove otherwise (the “investigations” are often pathetic jokes – not even a good dog & pony show).

    Several North Carolina patients have had the same experience. There are at least two cases I know of where patients (or the family members who survived them) sued the Medical Board to make them play fair. Settlements of those lawsuits brought about changes to the Medical Practice Act – and the way Board members are chosen.

    But it has not been nearly enough, and/so I expect I shall be joining that club very shortly.

  • http://Meyersmedmal.com JIvanmeyers

    dr Hossfeld,
    Did you read the article you cited? You certainly don’t reflect the open mind the authors of the article recommend in the excerpt below.

    ” We thus recommend that the health policy and health services research communities acknowledge that there is not strong epidemiological evidence to support either position and that we should keep an open mind while awaiting more rigorous evidence on this topic (Hayward and Hofer)”

    Further, you neglected to mention the nature of their major criticisms. They were unable to poperly evaluate two major studies the iom report relied upon for the percentage range of preventable deaths because the underlying data was no longer available. Of more interest to me personally, was the concern of your cited authors there was no consideration of the percentage of patients who would have died even if they had been treated properly.

    A wrongdoer should not question the magnitude of the chances which they, by their wrongdoing have placed beyond the possibillity of realization.

    • joe

      Mr Meyeres it was not Dr Hossfeld who left the reference it was me and yes I have read the reference, the IOM study and f/u’s, the NEJM letter from one of the original IOM authors citing issues with his own study, and most of the replies to the IOM studies over the years. You clearly have not. I am going to paste my reply to you above as you clearly did not read it.

      Mr Meyers:
      I think you actually have to READ the 1999 IOM report and and Dr Leape’s f/u reports before critiquing what it says, as clearly you have not. One of Dr Leape’s main points is the majority of the time the problem is not one doc committing malpractice rather a systems error at multiple levels. Frankly, your crosswalk analogy is meaningless in the majority of med errors. That doesn’t make a systems error “OK”, but it does mean the answer is a lot more complex that the soundbites you use. For example, many of us in the business know a real help would be one nationwide electronic medical record system which would minimize errors, ease evaluating medical records, and minimize duplication of services. That will never happen, partially because civil rights advocates (lawyers) have argued long and hard about the possibility of infringements on a patients record and partially because congress has been paid off by different software vendors who will reap billions. In the end we will have hundreds of systems that don’t talk with one another at the costs of billins of dollars, and still have the same problem.

      I find it curious that if you use the word “evildoers” for “wrongdoer” in your sentance, you get the mindset of the previous presidential administration. Try actually critically reading the IOM report, f/u reports, and the reference listed instread of mining for soundbites to justify your argument. The issue is a lot more complex than soundbites.

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