Alliance for Patient Safety

Boaz Lev:

Firstly, it is indeed difficult to hear and the events are terrible and horrific. Terrible and horrific and my heart and the heart of all of us, I think that the heart of the physicians and nurses and all of them together, are with the parents.

Amiad Taub:

But six years nobody called to say hello. I understand that the heart is with us, but not the voice.

The chairperson Karin Elharar:

It is in the heart.

Amiad Taub:

In the heart yes. It stayed in the heart.

Boaz Lev:

The things are terrible and horrific and I want to separate of course between the terrible things that occurred to Ofek Taub R.I.P and Eden Tverya R.I.P which are really, in the case of Ofek Taub R.I.P it is criminal, it is being handled by the police and the Attorney General's office. It is out of our custody —

The chairperson Karin Elharar:

No, but about the things that you are talking about.

Boaz Lev:

One moment, give me a minute, I shall soon explain. In regards to the formal process of the disciplinary handling. This, versus the alleged quality handling of fixing the system, then first of all, it might have happened not fast enough. As of today I can show you few means. Firstly the letter of the Safety Treatment Array about errors in connecting medical gas to the patient, which practically has been distributed to the entire system and obligating the entire system as to how —

Amiram Taub:

When was it distributed?

Boaz Lev:

It was distributed in —

Call:

In October 2012.

Bezalel Smotrich ( Habait Ha Yehudi):

The question whether anybody had checked it? Do you have an audit? Do you know today to say that in the operating rooms there are no CO2 taps?

Amiad Taub:

It had been distributed a year and half —

The chairperson Karin Elharar:

Moment, one moment, let's do it in an orderly manner.

Boaz Lev:

The answer is yes. The answer: these things are checked, of course.

The chairperson Karin Elharar:

Dr. Lev, let's do it in an orderly manner. Will there be in Hadassah —

Amiad Taub:

A year and a half —

The chairperson Karin Elharar:

Amiad, let's check. Will there be in Hadassah operating rooms managers who are also physicians?

Boaz Lev:

Sorry?

The chairperson Karin Elharar:

Operating rooms managers who are also physicians – will there be such a thing?

Boaz Lev:

Of course. The manager of the operating rooms array —

The chairperson Karin Elharar:

Does it exist?

Boaz Lev:

We have here the Hadassah representative, he maybe can —

The chairperson Karin Elharar:

No, I don't want to hear the Hadassah representative.

Boaz Lev:

The answer is yes.

Asher Shalmon:

It does exist.

The chairperson Karin Elharar:

Since when?

Asher Shalmon:

We are also appointing now a new manager —

The chairperson Karin Elharar:

Sir, since when does it exist?

Boaz Lev:

As of November 1^st a manager has been appointed to room —

Asher Shalmon:

For the sake of the issue Prof. Weisman took responsibility and also Sergei Guttman. We are appointing a new manager in the coming month, a man coming out of the Hadassah system —

The chairperson Karin Elharar:

Thank you. What is your position, sir?

Asher Shalmon:

My name is Dr. Asher Shalmon, I am the Deputy General Manager of Hadassah hospital.

The chairperson Karin Elharar:

Thanks a lot. Next question: in each room in which children are anesthetized there will be children's anesthetizing equipment. How is this supervised and whether there is specific equipment for children at all?

Boaz Lev:

The answer is: there is specific equipment for children. Of course also the dimensions are different. These things are being checked by the Medical Administration when it arrives and renews the license to the hospital.

The chairperson Karin Elharar:

How often does it happen?

Boaz Lev:

It happens once a year, once in two years, depending on the pace, that is to say how long it took them to get the license, but there are also random checks where they arrive to the hospital and check. Incidentally, today most of the hospitals are in the process of JCI, recognition and receipt of international standard accreditation and most of the hospitals have already passed this process. It of course requires stringent examination of all the standards obligating treatment of children.

Mordechai Yogev (Habait Ha Yehudi):

One moment, I do not accept the answer, sorry my lady.

The chairperson Karin Elharar:

Please sir.

Mordechai Yogev ( the Jewish Home):

When we are talking about hospitals and when we are talking about cowsheds – they have standards 2000, now 3000. Elevators today – last time checked on 9 / 2016, next check 9 / 2017. You say it is checked once a year, once in two years. It is not a serious answer on medical undertaking.

Boaz Lev:

Maybe the Medical Administration will say how exactly they do it.

The chairperson Karin Elharar:

Once in three years he said.

Mordechai Yogev (Habait Ha Yehudi):

A label is required which says checked on this and that date, the next check is on this and that date.

Boaz Lev:

There is a plan and this is done according to an organized plan and orderly licensing.

The chairperson Karin Elharar:

Come and sit around the table so we could hear you on the microphone. Please introduce yourself.

Piras Haiak:

My name is Piras, I am the representative of the Medical Administration of the Ministry of Health. Dr. Lev mentioned that the audits are done within a year, two or three. It is also very dependent on the findings of those audits. Sometimes the audit team issues a positive audit and then it decides that it is giving an extension for the license renewal within x years and therefore in audits which are more difficult, then the time periods for conducting the audits is shortened and therefore it says that there are audits that we decide that it is imperative to go to that hospital within one year. In better and  more positive audits, then we the extend the duration of their license validity. That was the intention.

Boaz Lev:

Also for the standard accreditation there are international standards how this thing works. Incidentally, it is checked not only by the Ministry of Health, it is checked by an international authority located in the United States, and it grants this standard accreditation and according to its timetable and it also renews this standard stamp according to the procedure, otherwise this standard accreditation is intrinsically invalid. It has very clear and fixed time tables and I think that in this respect we are in a very very good process.

The chairperson Karin Elharar:

Embedding risk management process, including error or almost error reporting in all the hospitals, where does this thing stand?

Boaz Lev:

With your permission, I can show a short presentation.

The chairperson Karin Elharar:

We have no time for a presentation, so if you could?

Boaz Lev:

First of all there is a very very extensive array of reporting. There are things that must be reported according to procedure and according to law and these are exceptional events.

The chairperson Karin Elharar:

Such as, for example?

Boaz Lev:

For example, providing erroneous blood unit. For example, a person that arrived to a hospital and the circumstances of his death are unclear and he died within 24 hours and there was no time to clarify the circumstances of his death.

The chairperson Karin Elharar:

For example a child that received carbon dioxide?

Boaz Lev:

Of course, of course.

The chairperson Karin Elharar:

Why it did not appear in the reports?

Boaz Lev:

No, no, it is clear. That is to say a child that died as a result of an error or a mistake, it is obligatory to report immediately and therefore I said that it is a 24 hours event.

The chairperson Karin Elharar:

What are the sanctions if it is not reported?

Boaz Lev:

If it is not reported? First of all —

Amiad Taub:

There is no sanction.

Call:

What is done —

Boaz Lev:

No, it is not precise. First of all the sanction is a criminal sanction. As long as it is not reported and an event had occurred that obligates reporting, first of all it is investigated.

The chairperson Karin Elharar:

Dr Lev, with your permission I want to make a distinction. There is the legal event. Now we go to the courts and all of us live in Israel and understand that what starts today is slated to end somewhere at the end of Tamuz or beginning Elul 2021. And then there is real life.

Boaz Lev:

Correct.

The chairperson Karin Elharar:

In real life many people arrive daily, toddlers, elderly, people of younger age and they are assisted by the services of the physicians. In general, and truly Mr. Taub justifiably said, that generally the State of Israel is very advanced medically, however a failure has occurred. Everyone understands that a mistake occurred. Can we rely today that a person who made an error, is removed from the system at least by the disciplinary court of the hospital?

Boaz Lev:

No, no. Come on, I want to clarify.

The chairperson Karin Elharar:

Why not?

Boaz Lev:

Because this had been determined by the legislator.

Call:

Not everyone should be removed —

The chairperson Karin Elharar:

Not to remove, but to investigate.

Call:

You said removed.

The chairperson Karin Elharar:

No, removed for the purpose of investigation. Temporary suspension.

Abdallah Abu Maaruf ( Hareshima Hameshutefet):

After investigation of course.

Boaz Lev:

I want to clarify. Can I clarify?

The chairperson Karin Elharar:

Of course. We have been assembled here for this reason.

Boaz Lev:

When such an event occurs, the Safety and Quality Array of the Ministry of Health, together with the Medical Administration and us, approach the hospital's General Manager and say, listen, an event occurred here which should not occur. You have the authority and professional responsibility, suspend the person, stop, take him out of the system —

The chairperson Karin Elharar:

Where is the regulator?

Boaz Lev:

Now, exactly. The regulator can suspend a physician for example according to the Physicians Ordinance only subject to a hearing, subject to clause 44 a, when it involves an event that put people's lives immediately at risk.

The chairperson Karin Elharar:

Why not? By all means! Perform a hearing.

Boaz Lev:

We do perform a hearing when we have an event, someone whose type of —

Amiad Taub:

There was this tap that we did not hear from them. For a year and half, first with us and after five months they did not change it. What is a better reason than that, they did not move the tap. To perform a hearing at the Ministry of Health? I understand that it is difficult, that it is complicated —

Boaz Lev:

With your permission, a hearing was performed, there was a committee that investigated it and went to the crux of the matter and also said what is needed to be changed so that such things will not reoccur. The removal of the hospital's general manager for that purpose, not that I am defending him, the removal of the operating rooms manager would not have changed this activity. It is an activity which has to be conducted on behalf of the hospital's general manager, to change immediately the procedures and to see that these things occur, even though they did not occur. Therefore the Attorney General's prosecution also puts on trial those responsible for this issue.

The chairperson Karin Elharar:

No, but sir —

Boaz Lev:

It is not us. One more time —

The chairperson Karin Elharar:

Sir, again, I have made the distinction not for no reason —

Amiad Taub:

We are waiting for the Attorney General's prosecution for six years?

Boaz Lev:

The answer is yes.

Amiad Taub:

Yes? But there is also your committee of the year —, your own committee of inquiry.

Boaz Lev:

I want to explain.

The chairperson Karin Elharar:

I made this distinction between the legal proceedings conduced in the Attorney General's prosecution and the proceeding conducted currently for a reason. First of all in this specific case —

Boaz Lev:

Then I want to explain.

The chairperson Karin Elharar:

We are witnessing the fact that had it not been for one righteous physician in Sodom who secretly called the parents, it would have not been discovered.

Boaz Lev:

I do agree with you.

The chairperson Karin Elharar:

And everyone understands the situation.

Boaz Lev:

Correct.

Dan Bental:

I want to tell you what we had found in this field in the audit, it is very important to focus the situation which is by far more severe than what has been said here. The situation is that in the hospitals they do not check almost anything and if they do already check it, we have compared it, we took -, one second, I shall start from the beginning.

We have compared it to the Air Force. In the Air Force, a pilot who makes mistakes, he tells the complete truth and there is openness to accept the explanations. He is not punished, nothing. In the hospitals —

Yael Geman (Yesh Atid):

Correct. It is not held against him.

Dan Bental:

It will not be held against him, correct. In the hospitals the situation is that debriefings are not conducted. Since the case of Gilad, that also has happened at Hadassah, no real debriefings are conducted, but we have heard that there are some department discussions, which are written and afterwards the papers are torn, so that, God forbid, nobody could find them.

Asher Shalmon:

This is not correct. Definitely not.

Dan Bental:

And we had commented on it and also in this area it necessitates cooperation of the Ministry of Justice, of the Ministry of Health. We have called upon you to come and resolve this problem, that there will be true debriefings. Today there are no debriefings.

Bezalel Smotrich (Habait Ha Yehudi):

I want.

The chairperson Karin Elharar:

Knesset member Smotrich , please.

Bezalel Smotrich (Habait Ha Yehudi):

I will do it really in three very short briefings due lack of time. First of all I want to take off my hat in respect when facing the families. Proper disclosure, I know Amiad already some few years. Seeing how a person is taking the hardship, establishes a voluntary association and assists the families today in similar situations, really amazing. Lots and lots of strengths is needed for that. So I say it really to all the families, God forbid that none of us shall be in your place, but you deserve all manners of respect, becoming to you.

Mistakes do happen. I am a very small fan of beheading people just for the sake of beheading, but the fact is that in systems where we might make mistakes, we have to do everything within our power that mistakes will not occur. That is to say, we cannot come and say, ok, mistakes happen, we are all human beings, never mind, mistakes are made, let’s march forward. I did not say that every physician that made an error should be thrown to the dogs. He should not be hanged in the town square, but again, in fact, since the system is very burdened and works in high level of tension, and treats tens and hundreds of thousands of patients, so there be, exactly as in the example of the army. Since the army is present at the situation where accidents may occur, then it protects itself in safety belts and suspenders and countless training events in order to make sure that these things do not happen.

Our impression is, not only from these cases, that this does not occur well enough in the Ministry of Health. One moment, one second, I am not going to land the entire responsibility only on your shoulders. It does not occur in the Ministry of Health. Knesset member German said earlier correctly, there are here also structured problems. These are friends. Many years of working together. I shall say what interests me in order that we move forward, since at the end of the day, the issue is not to give here —

I would very much like to understand by which power are these committees acting? It is by the law?  It is by regulations? Who appoints them? What is the validity of the reports they issue? Are there teeth to these reports, no teeth? The question of the debriefing is critical in my point of view. The fact that there is no confidentiality nor there is immunity – for being put on a criminal trial and no … speaking of a defensive medicine – and no debriefing in civil claims in a similar manner, that is what kills the debriefings.

You, in the Ministry of Health, must lead a process, in which, similarly to what occurs in the IDF, immunity is granted to these debriefings, since the debriefing is first and foremost – and the families have stated correctly, and I assume that if we ask them they will confirm – it is much more important for them, it is important for them by far that these things will not happen to their neighbor and their friend and to anyone else, than to receive any compensation due to them.

So if we want that the debriefings will be true, we must verify that the committees are such committees that are valid, that they are independent, that they are bound by timetables. That is to say, that the committees must work by timetables and that the implantation of the corrective measures must be done within timetables. A legal mechanism must be created which provides immunity to the physicians and nurses in the debriefing, in order that there is a debriefing in which they could talk openly, without being afraid that tomorrow it would be used against them. Incidentally, in the army as well, the fact that you have said something in the debriefing and you have immunity does not say that you do not face criminal court afterwards, but what you said under that immunity is not used against you.

This mechanism must be created here —

A call:

Very correct.

Bezalel Smotrich ( Habait Ha Yehudi):

And here you tell me that you agree with a nod of your head. This is not enough. You have to lead it in the Ministry of Health.

Boaz Lev:

No, then I shall explain. If I were allowed to show then I would have shown.

The chairperson Karin Elharar:

Yes please, Dr. Lev.

Bezalel Smotrich (Habait Ha Yehudi):

Only one more sentence. I do not know if it is possible and I shall be glad to receive a letter. That somebody may sit in the Ministry of Health and write to the committee about the entire procedure of how the seniors and the committees and these things work —

Boaz Lev:

That is what we wanted to prepare.

Bezalel Smotrich (Habait Ha Yehudi):

And then we shall put the finger on the failure points and we shall be -. We are not against you, not the families and not the committee.

The chairperson Karin Elharar:

Dr. Lev.

Boaz Lev:

I shall say briefly.

The chairperson Karin Elharar:

One moment, wait a second. I shall let you speak. I promise. I shall say something and then I will let you speak you and then we summarize until the following discussion, which of course will happen. Look, I want us to arrive to the next discussion and then we can advance forward. This discussion was only a preamble, it was important. We said the things. Not everyone got the opportunity to talk, I apologize to those that did not. I shall only say the next thing:

Look, it is important for us to know what has been done, in order to understand what is lacking and also you Sir to understand that it is lacking. I want to know another thing, I understand that there is a legislative memorandum, so is has already started and in a short time will be submitted. I want to know when it is going to be submitted to the Knesset. Please.

Boaz Lev:

Then I want to say that was I able to show the presentation, a large part of the issues would have been redundant. There is such a mechanism in place. There is a mechanism of debriefing, it is embedded in the entire medical system. There is a mechanism which is protected and confidential and the treating physicians are protected.

Mordechai Yogev (Habait Ha Yehudi):

Karin, two words.

Boaz Lev:

Sorry, one minute. I want to explain. And it is the mechanism of the quality and control committee according to the Patient's Rights Law and such a mechanism exists, and the things done within this framework are not —

Mordechai Yogev (Habait Ha Yehudi):

This is not executed.

The chairperson Karin Elharar:

Dr. Lev, This is not working in practice.

Mordechai Yogev (Habait Ha Yehudi):

This is not working.

Boaz Lev:

It is definitely working in practice, we were —

The chairperson Karin Elharar:

Well, ok.

Call:

What are you saying now? I thought that you will say that you agree that there are failures, let's fix them together. But you are saying that everything —

Boaz Lev:

On the face of it I agree that there are failures. Not this is the failure. Now, since the discussion is —

Yael German (Yesh Atid):

Boaz, when will the memorandum be submitted?

Boaz Lev:

One moment, give me a second, two things. Let’s do things one at a time. The memorandum is ready. And it is now with the Minister and the General Director for final approval. That's all. It's there.

Yael German ( Yesh Atid):

When will it be submitted?

Boaz Lev:

You want me to speak on their behalf? I hope that it will be submitted in the upcoming month. It is what I hope. It is finalized. To our liking it is finalized and enclosed and it also speaks of the non – dependability, but I want to say one more time —

The chairperson Karin Elharar:

Boaz, I am requesting to receive the presentation in the committee.

Boaz Lev:

Gladly. The presentation is with you, but I am asking that on the next opportunity to make a presentation in an orderly manner, so that you understand that there is the Complaints Commission which doesn't stop. It is in fact a gathering body which is limited by the fact that it works with lawyers and according to evidence etc. By contrast, the debriefings according to the Quality and Control committees are not bound by same rules and whatever has been collected by them cannot be used as evidence, in order that the people will not incriminate themselves. Both of these mechanisms are active. They have totally different time frames. These two channels operate in parallel. When an event occurs that the debriefing and quality and control committees have to be immediately activated and not only in this case, we are doing it along very many occurring events.

And therefore I think that it is necessary to separate and it is necessary to understand how this array works. Incidentally, also the long duration that it took between the committee of Ofek Taub to where we stand today, where there is a claim, that is to say that it is with the Attorney General's prosecution, most of the time this matter was at the hands of the police and so we —

Amiad Taub:

But — that was no, and you publicized a committee. Why didn't you investigate the physicians or suspended them?

Boaz Lev:

One minute. I want to explain. Give me only —

The chairperson Karin Elharar:

One moment, Amiad.

Amiad Taub:

Eh, really, all this bullshit. Let him show for once something with teeth that they did.

Boaz Lev:

Let me only explain. First of all, with teeth – all the systems were changed. These are the teeth.

We want that it will not happen to the next person. Now —

The chairperson Karin Elharar:

Well, Sir, one moment, period. Yes please Knesset member Yogev and after him Knesset member Abdallah Abu Maaruf. Each one gets to say one sentence.

Mordechai Yogev (Habait Ha Yehudi):

Two sentences. I shall really be concise out of appreciation to the entire medical system

that does nights as days, however at the same time, from the severity of the events and due

to their prolongation, going over five – six years in these stories —

Boaz Lev:

This is the Court of Law.

Mordechai Yogev (Habait Ha Yehudi):

Not only. You know that not only. I think Madam, that the weighted reply to this issue will be that the follow-up meeting and especially because of the things Prof. Lev is saying —

Boaz Lev:

Doctor.

Moedechai Yogev (Habait Ha Yehudi):

Doctor Lev says that within one month there will be results I think that the weighted reply is that the follow-up meeting should take place in this session within one month and one week.

The chairperson Karin Elharar:

Then I want to announce when will be the follow-up meeting.  Abdalla,  a sentence please.

Abdalla Abu Maaruf (Hareshima Hameshutefet):

Well, thanks for the discussion, Honorable Chairperson and I feel the pain of the families. Thanks for the courage that they have come and displayed their cases which are very saddening. I feel you and feel the pain.

In short, we have to differentiate in the next discussions, and I will not talk now much. I am a physician for 20 years and I am in the system and these matters are well known, but we must differentiate between negligence, which is a matter below the red line, and between mistakes and we shall not mix here. Why? Because negligence should not pass like nothing. It should be known what are deterrence and prevention. These are the issues about which we need to talk and not mix erroneously between negligence and the mistakes, and to each is its rule. It is very important and must be professional.

The chairperson Karin Elharar:

Thanks. I am sorry. One word, please.

Call:

We want to talk also about the bond physician – patient —

The chairperson Karin Elharar:

No, no. Sorry, Madam.

Dan Bental:

One word. We have checked and found that investigation committees were not established at all during its sampling period, not in Ichilov, not in Sheba, not in Wolfson, and not in Barzilay. One committee was set at Belinson. From the aspect of the quality and control committees, these were also not established at all, not in Sheba, not in Asaf Harofe, not in Bney Zion, not in Hillel Yaffe, not in Hadera. In short, there are no committees.  We shall gladly receive information that in the meantime —

Boaz Lev:

No, but —

The chairperson Karin Elharar:

No, no.

Boaz Lev:

But —