DOCSLIB.ORG

Volume 3 – a Strategy for Safety

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Volume 3 – a Strategy for Safety Public Inquiry into the Safety and Security of Residents in the Long-Term Care Homes System REPORT The Honourable Eileen E. Gillese Commissioner Volume 1 – Executive Summary and Consolidated Recommendations Volume 2 – A Systemic Inquiry into the Offences Volume 3 – A Strategy for Safety Volume 4 – The Inquiry Process Public Inquiry into the Safety and Security of Residents in the Long-Term Care Homes System REPORT The Honourable Eileen E. Gillese Commissioner Volume 1 – Executive Summary and Consolidated Recommendations Volume 2 – A Systemic Inquiry into the Offences Volume 3 – A Strategy for Safety Volume 4 – The Inquiry Process This Report consists of four volumes: 1. Executive Summary and Consolidated Recommendations 2. A Systemic Inquiry into the Offences 3. A Strategy for Safety 4. The Inquiry Process ISBN 978-1-4868-3586-7 (PDF) ISBN 978-1-4868-3582-9 (Print) © Queen’s Printer for Ontario, 2019 Disponible en français VOLUME 3 Contents VOLUME 1: Executive Summary and Consolidated Recommendations VOLUME 2: A Systemic Inquiry into the Offences VOLUME 3: A Strategy for Safety Dedication ......................................................... iv Acronyms and Abbreviations .................................... .v Chapter 15: Building Capacity and Excellence in the Long‑Term Care System ...................................... 1 Chapter 16: Building Awareness of the Healthcare Serial Killer Phenomenon ................................... .25 Chapter 17: Deterrence Through Improved Medication Management .................................... 71 Chapter 18: Detecting Intentionally Caused Resident Deaths ............................................. 133 Chapter 19: Suggestions Not Pursued ......................... 173 Appendices ...................................................... 183 Appendix G – A Just Culture Guide ............................... 184 VOLUME 4: The Inquiry Process Dedication Volume 3 of the Report is dedicated to the many nurses and other caregivers who perform their jobs in the long-term care system with great kindness and skill. Our Strategy for Safety cannot succeed without their continued dedication to those in their care. In opening our eyes to the one nurse who harmed, we must not forget the work of the many who are a credit to their professions. Acronyms and Abbreviations v Acronyms and Abbreviations ADC automated dispensing cabinets ADR alternative dispute resolution APR automated provider reports BCMA barcode-assisted medication administration BPMH best possible medication history CAMH Centre for Addiction and Mental Health CCAC Community Care Access Centre CCF complaint, critical incident and follow-up CFS Centre of Forensic Sciences CIAF Canadian Incident Analysis Framework CIATT Centralized Intake, Assessment and Triage Team CIHI Canadian Institute for Health Information CIS Critical Incident System CLRIs Centres for Learning, Research and Innovation cMAR computer-generated medication administration record CMI Case Mix Index CNO College of Nurses of Ontario COPD chronic obstructive pulmonary disease CVA cardiovascular accident CVH cardiovascular heart disease DIOC Death Investigation Oversight Council DNR do not resuscitate DOC director of care DON director of nursing EDB emergency drug box eMAR electronic medication administration record ESPA External Service Provider Agencies Policy ETMS events tracking management system Public Inquiry into the Safety and Security of Residents in the Long-Term Care Homes System vi Volume 3 n A Strategy for Safety FPU Forensic Pathology Unit FTE full-time-equivalent (employee) HCCSA Home Care and Community Services Act, 1994 HCSK healthcare serial killer HESP Health, Education and Social Policy (Committee of Cabinet) HNHB Haldimand Niagara Haldimand Brant HQO Health Quality Ontario HSARB Health Services Appeal and Review Board HSIM Health System Information Management (Division) HSMR hospital standardized mortality ratio HSP health service provider HSSP Health and Social Services Policy (Committee of Cabinet) IALP Inter-Agency Leadership Partnership I/CAD Intergraph Computer Aided Dispatch ICRC Inquiry, Complaints and Reports Committee IPDR Institutional Patient Death Record IQS Inspector’s Quality Solution ISMP Institute for Safe Medication Practices LHIN Local Health Integration Network LHSIA Local Health System Integration Act, 2006 LQIP Long-Term Care Home Quality Inspection Program LRPA Long-Term Care Home Quality Inspection Program Risk Performance Assessment LSAA Long-Term Care Home Service Accountability Agreement LTC long-term care LTCH Long-Term Care Home (Division) LTCHA Long-Term Care Homes Act, 2007 LTCI Long-Term Care Homes Public Inquiry MAPLe Method for Assigning Priority Levels MAR medication administration record MAR/TAR medication administration record / treatment administration record Acronyms and Abbreviations vii MDS Minimum Data Set MOU memorandum of understanding MPP Member of Provincial Parliament NHA Nursing Homes Act NHP Nurses’ Health Program NP nurse practitioner NPC nursing and personal care OARC Ontario Association of Residents’ Councils OCC Office of the Chief Coroner OCD obsessive compulsive disorder OFPS Ontario Forensic Pathology Service OHIP Ontario Health Insurance Plan OIC Order in Council OLTCA Ontario Long Term Care Association ONA Ontario Nurses’ Association OPA Ontario Pharmacists Association PAC Professional Advisory Committee PFPU Provincial Forensic Pathology Unit PIA Public Inquiries Act, 2009 PICB Performance Improvement and Compliance Branch PICC peripherally inserted central catheter PLP Preceptee Learning / Developmental Plan PME Post Mortem Examination POM provider operations meeting PRN pro re nata (“as needed”) PSW personal support worker RAI Resident Assessment Instrument RAI-CA Resident Assessment Instrument – Contact Assessment RAI-HC Resident Assessment Instrument – Home Care RAI-MDS Resident Assessment Instrument–Minimum Data Set RCPSC Royal College of Physicians and Surgeons of Canada Public Inquiry into the Safety and Security of Residents in the Long-Term Care Homes System viii Volume 3 n A Strategy for Safety RHPA Regulated Health Professions Act, 1991 RL6 system electronic complaint / incident reporting system (Saint Elizabeth Health Care) RN registered nurse RPN registered practical nurse RPNAO Registered Practical Nurses Association of Ontario RQI resident quality inspection RSC regional supervising coroner SAO Service Area Office SCAN Suspected Child Abuse and Neglect (Program) SDM substitute decision-maker SIU Special Investigations Unit SW CCAC South West Community Care Access Centre SW LHIN South West Local Health Integration Network TAR treatment administration record WHMIS Workplace Hazardous Materials Information System WSIB Workplace Safety and Insurance Board CHAPTER 15 Building Capacity and Excellence in the Long-Term Care System I. Introduction ..................................................... 2 II. Systemic Issues Demand a Systemic Response ................ .3 III. The Current System – A Solid Foundation on Which to Build ........................................................... 5 A. The LTCHA and Regulation ................................... .6 B. The People and Organizations in the LTC System ............. 7 1. Pro-active Stakeholder Initiatives ................................ .8 2. Ongoing Stakeholder-Led Innovation ............................ 11 IV. Building Capacity and Promoting Excellence in the LTC System ................................................. 13 A. Prevention – the Impetus for Change ........................ 13 B. An Expanded Ministry Role .................................. .14 1. Support for LTC Homes in Achieving Regulatory Compliance ...... .16 2. Spreading Best Practices Across the LTC System ................... 17 3. Funding Bridging and Laddering Programs in LTC Homes ......... .18 4. Encouraging Innovation and the Use of New Technologies ........ .19 V. Conclusion ...................................................... 20 RECOMMENDATIONS ................................................... 21 Public Inquiry into the Safety and Security of Residents in the Long-Term Care Homes System 2 Volume 3 n A Strategy for Safety I. Introduction Based on the evidence I heard in the public hearings, it is my view that systemic failings in the long-term care (LTC) system – not individual ones – created the circumstances that allowed Wettlaufer to commit the Offences. In this volume of the Report, I describe the systemic vulnerabilities identified through the Inquiry processes and propose systemic responses that must be taken if we are to avoid similar tragedies in the future. These responses are designed to prevent, deter, and detect wrongdoing of the sort that Wettlaufer, a healthcare serial killer (HCSK), committed. This chapter is devoted to strategies whose goal is prevention. Later chapters in this volume are directed at the strategies for deterrence and detection. I begin this chapter by considering why systemic issues demand a systemic response. In the next section, I explain that although the LTC system is grappling with serious challenges, it is far from broken. In the section that follows, I call for the Ministry of Health and Long-Term Care (Ministry) to play an expanded leadership role. In fulfilling this expanded role, the Ministry will strengthen the LTC home system through capacity building and the sharing of excellence. I call for a new unit in the Long-Term Care Homes Division to support LTC homes in achieving regulatory compliance and to spread best
Load more

Recommended publications
  • Strange, and Ultimately Dangerous, Credentialing Scenarios Highlight the Need for Msps’ Roles to Protect the Public
    Strange, and ultimately dangerous, credentialing scenarios highlight the need for MSPs’ roles to protect the public April 3, 2018 For those of you who were unable to join us at NAMSS this year, we thought you might enjoy a recap of our session regarding strange credentialing scenarios. It is true that fact can be stranger than fiction, but these situations make it very clear that the role of the MSP is critical in today’s fast-paced world. The Danger of Not Doing Your Homework We begin with a history lesson — Michael Swango. He was valedictorian of his class and awarded a National Merit scholarship. His favorite movie was “Silence of the Lambs,” and he kept a scrapbook of car wrecks. He graduated from medical school in 1983, and during that time, five of the patients he cared for died. He obtained a surgical internship and subsequently, despite a poor evaluation, a neurosurgery residency at The Ohio State University College of Medicine (from which he was ultimately terminated for slovenly work). His nickname was “Double-O Swango.” Nursing staff expressed their concerns, but administration thought they were being “paranoid.” He was licensed as a physician in the state of Ohio in 1984. This is where it gets interesting. In 1991, he legally changed his name to Daniel Adams after having been sentenced to five years in prison for aggravated battery — he poisoned his coworkers while working as an EMT. He then forged his criminal record to reduce the charge and created a “Restoration of Civil Rights” letter allegedly from the Governor of Virginia.
    [Show full text]
  • Serial Killers
    Serial Killers Dr. Mike Aamodt Radford University [email protected] Updated 01/24/2010 Types of Multiple Killers Mass Spree Serial # of victims 4+ 2+ 3+ # of events 1 1 3+ # of locations 1 2+ 3+ Cooling-off period no no yes Serial Killer Frequency • Hickey (2002) – 337 males and 62 females in U.S. from 1800-1995 – 158 males and 29 females in U.S. from 1975-1995 • Gorby (2000) – 300 international serial killers from 1800-1995 • Radford University Data Base (1/24/2010) – 1,961 serial killers • US: 1,140 • International: 821 – Number of serial killers goes down with each update because many names listed as serial killers are not actually serial killers Updated 01/24/2010 1 General Serial Killer Profile Demographics - Worldwide • Male – Our data base: 88.27% – Kraemer, Lord & Heilbrun (2004) study of 157 serial killers: 96% • White – 66.5% of all serial killers (68% in Kraemer et al, 2004) – 64.3% of male serial killers – 83% of female serial killers • Average intelligence – Mean of 101 in our data base (median = 100) –n = 107 • Seldom involved with groups Updated 01/24/2010 General Serial Killer Profile Age at First Kill Race N Mean Our data (2010) 1,518 29.0 Kraemer et al. (2004) 157 31 Hickey (2002) 28.5 Updated 01/24/2010 General Serial Killer Profile Demographics – Average age is 29.0 • Males – 28.8 is average age at first kill • 9 is the youngest (Robert Dale Segee) • 72 is the oldest (Ray Copeland) – Jesse Pomeroy (Boston in the 1870s) • Killed 2 people and tortured 8 by the age of 14 • Spent 58 years in solitary confinement until he died • Females – 30.3 is average age at first kill • 11 is youngest (Mary Flora Bell) • 66 is oldest (Faye Copeland) Updated 01/24/2010 2 General Serial Killer Profile Race Race U.S.
    [Show full text]
  • Quincy{Off the Record} the Famous & Infamous 13
    Quincy{Off the Record} the famous & infamous 13 bizarre brow-raising spooky spine-tingling astounding & amazing self-guided driving tour of places associated with some of the Quincy area’s intriguing former residents SEEO seequincy.com~ KEY to People and Locations to see MARY ASTOR 1 2435 N 12th Hollywood film star in The Maltese Falcon JENNIE HODGERS / ALBERT CASHIER 2 1707 N 12th Cashier’s secret identity as a woman MONCKTON MANSION 3 1419 Locust Mob activity & Queen Victoria-commisioned chandelier JOHN MAHONEY 4 1627 College Frasier star, the beloved Marty Crane JAMES B STEWART / MICHAEL SWANGO 5/6 220 N 18th Prize-winning author / “Dr. Death” serial killer JAMES EARL RAY 7 415 Hampshire Convicted assassin of Dr. Martin Luther King, Jr. JOHN ANDERSON 8 510 Maine Brilliant character actor in over 500 T.V. roles DICK BROTHERS BREWERY 9 9th & York “Sudsy” the ghost & underground tunnels ROY BROCKSMITH 10 1020 S 5th From bar singing at age 3 to Arachnophobia WOODLAND CEMETERY / JOHN WOOD 11 1020 S 5th 60,000 rest here, including Wood’s father’s “head” JONATHAN BROWNING 12 350 N Main World famous firearms inventor & polygamist Nauvoo ROBERT EARL HUGHES 13 400 E Jefferson World’s heaviest man at 1,041 pounds Pittsfield kochs ln us hwy 24 1 il veterans home 2 3 locust st quincy front st front univ college ave 4 mississippi river 8th st 6th st 4th st 5th st 3rd st 12th st 18th st broadway st us 24 to MO v vermont st 7 hampshire st 5/6 v washington park maine st 8 york st east end 9 historic district state st VISITOR CENTER/villa kathrine Hgardner expy 10/11 jefferson st 12 woodland cemetery NAUVOO 57 harrison st 96 south park QUINCY I-72 PITTSFLD 13 Mary Astor 1 1906-1987 An only child, Mary Astor was born Lucile Langhanke on May 3, 1906 in Quincy, to German immigrant father, Otto Langhanke, and mother from Illinois, Helen Vasconcellos.
    [Show full text]
  • Credentialing: Details, Details, Details
    3/3/2020 Credentialing: Details, Details, Details Ann Geier, MS, RN, CNOR(E), CASC® Chief Nursing Officer Surgical Information Systems (SIS) 2 1 3/3/2020 Objectives At the conclusion of this program, the attendee will: 1. Understand the differences between Credentialing, Privileging, and Peer Review 2. Develop steps in the credentialing process that will safeguard the ASC 3. Establish guidelines to ensure that physicians are safe to practice in your ASC 3 Why is Credentialing So Important? • From 2001 – 2011 nearly 6,000 doctors had clinical privileges restricted or taken away for misconduct • But 52% — more than 3,000 doctors — were never fined or hit with a license restriction, suspension or revocation by a state medical board.¹ • In 2012, 6949 adverse action reports were submitted to NPDB² • Impersonators 2 NPDB 2012 Annual Report, 55 4 2 3/3/2020 Do You Know Who This Is? 5 Michael Swango, MD 6 3 3/3/2020 Michael Swango, MD • In 2000, pleaded guilty to murdering 3 patients by poisoning them while a hospital physician. He is suspected of administering lethal injections to 35 – 60 patients • If hospital had done its job, it would have learned: » Medical school wrote warning letter » Numerous deaths occurred during his rounds » Convicted & imprisoned for 2 years for poisoning coworkers » Pled guilty to fraud in applications to government hospitals » Ohio revoked his medical license » Dismissed from programs and rejected by hospitals » Featured on 20/20 and America’s Most Wanted Blind Eye: How the Medical Establishment Let a Doctor Get
    [Show full text]
  • The BG News May 1, 1985
    Bowling Green State University ScholarWorks@BGSU BG News (Student Newspaper) University Publications 5-1-1985 The BG News May 1, 1985 Bowling Green State University Follow this and additional works at: https://scholarworks.bgsu.edu/bg-news Recommended Citation Bowling Green State University, "The BG News May 1, 1985" (1985). BG News (Student Newspaper). 4394. https://scholarworks.bgsu.edu/bg-news/4394 This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 4.0 License. This Article is brought to you for free and open access by the University Publications at ScholarWorks@BGSU. It has been accepted for inclusion in BG News (Student Newspaper) by an authorized administrator of ScholarWorks@BGSU. Wednesday, May 1,1985THE J3CL NEWS Vol. 67 Issue 119 College of Technology created by Michael Mclntyre Technology Systems and Department of 1983," Lunde said. "The increase in give a test, major quiz, or assign a Debate continued, and the Senate staff reporter of VisuaTComniunications and Tech- costs won't occur because it already major project during the week prior to finally decided to vote within itself nology Education. has." final exam week. whether or not to change the word. Faculty Senate voted yesterday to Most of the debate centered around He said the name change would add The resolution was changed to in- They voted in favor oi the change and change the name of the School of Tech- the budgetary implications of creating to the prestige of the technology pro- clude that laboratory tests and the immediately passed the resolution. nology to the College of Technology, a new college.
    [Show full text]
  • Lessons from the Worst-Case Scenario, Mar 04 ... AMA Journal Of
    Virtual Mentor. March 2004, Volume 6, Number 3. doi: 10.1001/virtualmentor.2004.6.3.oped2-0403 Op-Ed Lessons from the Worst-Case Scenario A system of physician self-regulation will help ensure patient safety and quality medical care. Erin Egan, MD, JD Michael Swango was a physician—and—a serial killer [1]. Swango killed hospitalized patients, those under his care or others just in the wrong place at the wrong time. To say that a serial killer is too personally culpable and too extreme to provide meaningful lessons on patient safety ignores the critical patient safety and system issues that we need to acknowledge and address to prevent harm to patients. Clinical case 2 in this issue, "Problem Peers," brings up the common scenario in which a physician represents a safety concern that peers are aware of. This scenario occurs everywhere, at every level of medical education. The Swango case illustrates how, even when the worst happens, the system is not effective at dealing with problem physicians. Michael Swango was a problem student and a problem resident. His medical school classmates feared for the safety of Swango's patients, calling him "double-O Swango," meaning he had a "license to kill" [2]. The high mortality among Swango's patients was noted by the students and residents he worked with as soon as he began clinical training [3]. He was dismissed from a residency position after the hospital suspected him of poisoning a patient—not through poor medical care but by injecting something into the IV of a patient who was not under his care [4].
    [Show full text]
  • Pre- and Post-Offence Behaviours of Healthcare Serial Killers As a Confidence Game
    Pre- and Post-Offence Behaviours of Healthcare Serial Killers as a Confidence Game by Christine Katherine Lubaszka A Thesis Submitted in Partial Fulfillment of the Requirements for the Degree of Master of Arts in The Faculty of Social Science and Humanities Criminology University of Ontario Institute of Technology October, 2012 © Christine Katherine Lubaszka, 2012 ABSTRACT Extant literature, while plentiful on the topic of serial homicide in general, does not adequately examine the phenomena of healthcare professionals who serially murder their patients. Using a sample of 58 healthcare serial killers located within North America, South America and Europe between the years of 1970-2010, this study examines notable pre- and post-offence behaviours of healthcare serial killers. Patterns related to offender etiology, victim cultivation, crime scene behaviour and techniques of evasion were explored. The findings from this study suggest that the pre- and post-offence behaviours of healthcare serial killers can be examined from the theoretical framework of confidence men or ‘con men.’ The findings from this study also suggest that healthcare serial killings and offenders who perpetrate them continue to be elusive and warrant additional scholarly attention to reduce their likelihood of engaging in homicide undetected for extended periods of time. Policy implications are also discussed. Keywords: serial homicide, healthcare serial killers, medical murder, clinicide, techniques of evasion, victim cultivation, confidence men, con men i ACKNOWLEDGEMENTS First and foremost, I wish to extend my sincerest gratitude to my master’s thesis supervisor, Dr. Phillip Shon, for his valuable expertise, support and patience throughout the last two years. From the very beginning of this process Dr.
    [Show full text]
  • OSBN Sentinel, November 2020
    OREGON BOARD OF NURSING [ VO.39V ▬ NO.4 ▬ NOVEMBER 2020 ] Also in this issue Freedom Of Speech, Hate Speech, And The Nurse Practice Act AA REGULATORYREGULATORY RESPONSERESPONSE TOTO HEALTHCAREHEALTHCARE SERIALSERIAL KILLINGKILLING Advanced training for YOUR advance nursing caree All of ASU’s MS in Nursing graduates Take the next step in your nursing career and earn your MS in Nursing! The 100% online are prepared to address MS in Nursing program from Arizona three main objectives: State University develops the in-depth skills you need to excel in a wide variety Deliver comprehensive of nursing and health care settings. nursing care in partnership When you enroll with ASU, you expand your with individuals, families, nursing skills with a deeper understanding groups and communities, of evidence-based practice, leadership, 1 pathophysiology and how to meet workforce and populations. demands. This graduate program is ideal for anyone looking to upgrade their nursing career while building on their own education. Develop theoretical and practice-based nursing education across diverse 2 care settings. Demonstrate knowledge and skills needed to analyze, use and generate evidence for 3 application to practice. Edson College of Learn more at Nursing and Health Innovation nursingandhealth.asu.edu/msnonline TABLE OF CONTENTS Oregon State Board of Nursing 17938 SW Upper Boones Ferry Road Portland, OR 97224-7012 SENTINEL Phone: 971-673-0685 ▬ ▬ Fax: 971-673-0684 [VO.39 NO.4 NOVEMBER 2020] www.oregon.gov/OSBN contentstable of ÑġßáÊëñîï Monday - Friday 8:00 a.m. - 4:30 p.m. ÒäëêáÊëñîï A Regulatory Response To Healthcare ÒäëêáÊëñîïîáàñßáàâëîðäáàñîÝðåëê Serial Killing ........................4 ëâðäáÉëòáîêëîĊïÇôáßñðåòáÑîàáîëê Covid-19.
    [Show full text]
  • Gilbert, Kristen
    Kristen H. Gilbert Information researched and summarized by Elizabeth Daly, Kanika Davis, Sarah DeHart, & Michael Palmadesso Department of Psychology Radford University Radford, VA 24142-6946 Date Age Life Event 11-13-1967 0 Born in Fall River, Massachusetts as Kristen Heather Strickland 1974 7 Younger sister Tara Morgan was born Early 80’s -- Family moved to Groton, MA Kristen showed signs of being a pathological liar, according to friends, neighbors, Early 80’s -- and father – often made the unfounded claim she was related to murderer Lizzie Borden 1984 16 Graduated high school a year and a half early, with high honors 1984 16 Enrolled in Bridgewater State College with a major in pre-med Developed a pattern of verbal and physical abuse towards boyfriends and ex- 1985 17 boyfriends Summer, 86 19 Met future husband Glenn Gilbert Transferred to Wachusett Community College, then to Greenfield Community 6-87 20 College, to be closer to Glenn (both schools in Massachusetts) Took a job as a home health aide with the Visiting Nurses Association of Franklin 1987 20 County. Used bathwater to scold a retarded child over 60% of his body. Was not prosecuted 1-88 21 Eloped and Married Glenn Gilbert (became Kristen Gilbert) 2-88 21 Chased her husband Glenn around the house with a butcher knife after an argument 1988 21 Graduated from Greenfield Community College with a diploma in nursing Became employed as a nurse at Leeds Veterans Affairs Medical Center in 03-06-1989 22 Massachusetts A pattern began to emerge of an unusually large number of deaths in Ward C, during 1990 23 Gilbert’s work shift there.
    [Show full text]
  • Armando D. Meza MD Associate Professor of Medicine Associate
    Armando D. Meza MD Associate Professor of Medicine Associate Dean GME TTUHSC-PLFSOM El Paso Program Directors Training Course Selected Topics PDTC-9 Disciplinary Policy Resident Evaluation: A Focus on Failing to Fail Michael Swango • Born: 1954, Tacoma, • Decision is made to delay his Washington. graduation date by one year. • Valedictorian in HS. • His dropped from his prior matched program but • He enrolled in Southern reapplies. Illinois University School of • In 1983 he starts a NS residency Medicine. at Ohio State. -- Performance uneventful • Unexpected patients’ deaths until his last year of school. are associated with him and his – 1983, matches for contract is not renewed. neurosurgery. • In 1984 he is rehired as an EMT. – He fails his last rotation due • In 1985 he is convicted of to plagiarism or fabrication. aggravated battery. – Case referred to the Student Progress Committee. Michael Swango • 1991 he changes his name to • 1994 his is working as a chemist Daniel J. Adams. in Atlanta. • In 1992 he is hired as a • 1994 he moves to Zimbabwe physician Sanford USD Medical and starts practicing medicine. Center in Sioux Falls with • He then crosses to Zambia and falsified application then Namibia. information. • 1997 he is arrested at Chicago- • Swango is fired a few months O’Hare on his way to Saudi later. Arabia. • Swango manages to start a • He eventually pleads guilty and Psychiatric residency at Stony is sentenced to 3 consecutive Brook but is fired when his past life terms. is discovered. Residents in Trouble • Typical scenario: • Reality: – Surprise – A pattern – Oddity – Overlooked – A fluke – Never addressed – An accident – Never remediated – A rare event – Allowed to continue – Give them another opportunity Potential Explanations • Faculty not competent • Do not want to “ruin” to identify these their career.
    [Show full text]
  • U.S. Dept. of Veterans Affairs Office of Inspector General Semiannual
    Office of Inspector General Semiannual Report to Congress April 1, 2000 – September 30, 2000 FOREWORD I am pleased to submit the semiannual report on the activities of the Department of Veterans Affairs (VA), Office of Inspector General (OIG) for the period ended September 30, 2000. The OIG is dedicated to help ensure that veterans and their families receive the care, support, and recognition they have earned through service to their country. This report is issued in accordance with the provisions of the Inspector General Act of 1978, as amended. Most significant in the protection of veterans was the prosecution of Dr. Michael Swango. After a 7-year investigation by our Office of Investigations, with assistance by our Office of Healthcare Inspections, Swango pleaded guilty in Federal court to the murder of three veterans under his care at a VA medical center (VAMC). He also admitted to the murder of a 19-year-old patient at a university hospital in 1984. Swango was sentenced to three consecutive life terms in prison with no possibility of parole. Our criminal investigations continue to target cases of public corruption and major thefts, instances where incapacitated veterans fall victim to unscrupulous individuals, and fraud involving programs for the delivery of benefits to veterans. We place a priority on safety and security at VA medical centers. Allegations of fraud demand an immediate response. The OIG will take decisive action against those who prey on veterans and will hold accountable those VA employees who disregard their public trust responsibilities. During the period, OIG criminal and administrative investigations yielded 174 arrests, 156 indictments, 122 criminal convictions, and 195 administrative actions, foremost of which were cases involving fraud and employee misconduct.
    [Show full text]
  • Criminal Poisoning FORENSIC SCIENCE- AND- MEDICINE
    Criminal Poisoning FORENSIC SCIENCE- AND- MEDICINE Steven B. Karch, MD, SERIES EDITOR CRIMINAL POISONING: INVESTIGATIONAL GUIDE FOR LAW ENFORCEMENT, TOXICOLOGISTS, FORENSIC SCIENTISTS, AND ATTORNEYS, SECOND EDITION, by John H. Trestrail, III, 2007 MARIJUANA AND THE CANNABINOIDS, edited by Mahmoud A. ElSohly, 2007 FORENSIC PATHOLOGY OF TRAUMA: COMMON PROBLEMS FOR THE PATHOLOGIST, edited by Michael J. Shkrum and David A. Ramsay, 2007 THE FORENSIC LABORATORY HANDBOOK: PROCEDURES AND PRACTICE, edited by Ashraf Mozayani and Carla Noziglia, 2006 SUDDEN DEATHS IN CUSTODY, edited by Darrell L. Ross and Ted Chan, 2006 DRUGS OF ABUSE: BODY FLUID TESTING, edited by Raphael C. Wong and Harley Y. Tse, 2005 A PHYSICIAN’S GUIDE TO CLINICAL FORENSIC MEDICINE: SECOND EDITION, edited by Margaret M. Stark, 2005 FORENSIC MEDICINE OF THE LOWER EXTREMITY: HUMAN IDENTIFICATION AND TRAUMA ANALYSIS OF THE THIGH, LEG, AND FOOT, by Jeremy Rich, Dorothy E. Dean, and Robert H. Powers, 2005 FORENSIC AND CLINICAL APPLICATIONS OF SOLID PHASE EXTRACTION, by Michael J. Telepchak, Thomas F. August, and Glynn Chaney, 2004 HANDBOOK OF DRUG INTERACTIONS: A CLINICAL AND FORENSIC GUIDE, edited by Ashraf Mozayani and Lionel P. Raymon, 2004 DIETARY SUPPLEMENTS: TOXICOLOGY AND CLINICAL PHARMACOLOGY, edited by Melanie Johns Cupp and Timothy S. Tracy, 2003 BUPRENOPHINE THERAPY OF OPIATE ADDICTION, edited by Pascal Kintz and Pierre Marquet, 2002 BENZODIAZEPINES AND GHB: DETECTION AND PHARMACOLOGY, edited by Salvatore J. Salamone, 2002 ON-SITE DRUG TESTING, edited by Amanda J. Jenkins and Bruce A. Goldberger, 2001 BRAIN IMAGING IN SUBSTANCE ABUSE: RESEARCH, CLINICAL, AND FORENSIC APPLICATIONS, edited by Marc J. Kaufman, 2001 CRIMINAL POISONING INVESTIGATIONAL GUIDE FOR LAW ENFORCEMENT, TOXICOLOGISTS, FORENSIC SCIENTISTS, AND ATTORNEYS Second Edition John Harris Trestrail, III, RPh, FAACT, DABAT Center for the Study of Criminal Poisoning, Grand Rapids, MI © 2007 Humana Press Inc.
    [Show full text]