Out-of-the-Box Lawyering

How to decrease medical malpractice suits by decreasing malpractice — Posting number 3 — How hospitals are increasing safety and reducing costs by preventing malpractice

Recently hospitals are being built or being remodeled to increase patient satisfaction and safety and, at the same time, reduce hospital costs. A recent article entitled "Newest hospitals display new thinking" is one of a number of articles that discusses how new hospitals are being built or remodeled with patient safety in mind. In fact, aerospace and industrial safety experts were consulted in designing one of the hospitals.

The article cites The Center for Health Design of Concord, CA, and notes that the Center's "analysis of more than 600 research studies proves hospital design can improve the outcome of patient treatment." Here are some examples of how hospitals have reduced patient injuries:

Patient falls decreased by 75 percent in one cardiac ICU after it spread out its nurses stations and placed the nurses closer to the patients. The article notes that treatment for a fall, assuming there is no lawsuit, can cost a hospital about $10,000. And how many of us have heard about the severe effects that patients can have due to one of those falls, including ultimately death from their inability to ambulate due to broken bones and pelvises. Not only are the redesigning hospitals saving money, they are preventing untold amounts of pain and suffering — and, indeed, deaths due to the falls.

Infections acquired in another hospital decreased 11 percent in new wings of the hospital where each room was made private and a sink was conveniently located for hand washing. (Normally, infections "cause tens of thousands of deaths" and cost hospitals "billions of dollars annually.")

Medical errors in two new inpatient units at another hospital decreased 30 percent "after medication rooms were expanded, medical supplies were reorganized and acoustical panels were installed to decrease distracting noise."

The article details the names of the hospitals and includes additional examples of how the redesign aided both the hospital, the staff and the patients. It makes interesting reading, and none of the solutions required rocket science.

How you can get the latest news on preventing malpractice suits by preventing malpractice

If you would like to keep up with new information about how hospitals and others are preventing malpractice suits by preventing malpractice, you can find the latest examples the same way I found the current article: You can go to Google and sign up for a News Alert using the term "medical errors" (with the quotation marks). I'm sure there are better ways of finding the latest news items. When you find the better ways, please pass them on.

If you're not familiar with using Google's "News Alerts" — Yahoo and CNN also have them — you can visit my website for a description of one of the relatively unknown ways that you can use Google. The posting is on "How you can get the latest news on Google. And how you can keep track of what news sources are saying about your clients and your opponents (and maybe even about you)."

My prior medical malpractice postings

This is my third medical malpractice prevention posting. The first relates to how the FDA has enacted a new rule requiring bar codes for blood and blood-related products. The FDA states that its change will result in a decrease over the next 20 years of over 500,000 blood-related "adverse events." That calculates to a potential saving of over 25,000 "adverse events" annually.

My second posting reports a study that concludes that an average of 195,000 people have died annually due to errors in hospitals. And that's just deaths — it doesn't include injuries. And that also just counts deaths due to in-hospital errors. It doesn't even include non-hospital related deaths or injuries.

Wouldn't it be great if the medical system was overhauled and there weren't any malpractice cases for lawyers to handle?

Here's a potential out-of-the-box defense for an aggressive client: My mother's drinking or her smoking made me do it — Just look — My arms (or legs or ears or feet or whatever) are not symmetrical

A study in the July/August issue of the American Journal of Human Biology concluded that the less symmetrical a person's paired body parts (such as arms, legs and ears) were, the more likely it would be that the person would show signs of aggression when provoked.

A detailed discussion in Medical News Today of the study made the following observations:

"Research showed that the farther certain paired body parts were from symmetry – if one ear, index finger or foot was bigger than another, for example – the more likely it is was [sic] that a person would show signs of aggression when provoked. The symmetry effects were different in men and women, however."

Although this does sound strange, here's what Medical News reports, including quotations from Zeynep Benderlioglu, one of the co-authors of the study:

"Deviations from symmetry are thought to reflect stressors during pregnancy – such as poor health, alcohol and tobacco use – that may affect development of the fetus in a variety of ways.

" ‘Paired body parts are presumably controlled by similar genetic instructions, so if everything goes perfectly you would expect paired body parts to be the same size,' Benderlioglu said.

" ‘But stressors during pregnancy may lead to asymmetrical body parts. The same stressors will also affect development of the central nervous system, which involves impulse control and aggression,' she said. ‘So while asymmetry doesn't cause aggression, they both seem to be correlated to similar factors during pregnancy.' "

The study also found that there were gender differences in the way that men and women handled different kinds of stress, and even within the same gender there were differences in the way that the tested subjects handled different kinds of stress.

Thus, Benderlioglu warned that stressors such as smoking and heavy alcohol use by pregnant women could lead to the poor impulse control.

You can see an abstract of the article at no charge; you can purchase a pdf copy of the article for $25.00

The Medical News summary includes a contact telephone number and e-mail address for Benderlioglu. It also links to an Ohio State version of the article. The Ohio State version (which may be the original version) includes links to the authors and to some additional information.

The out-of-the-box technique that got Nader on the Virginia presidential ballot — Maybe something else also helped

On Monday (August 23), the office of the Virginia attorney general, according to The New York Times, in an article by the Associated Press, reversed itself from a Friday ruling and held that the state's Board of Elections had to accept Ralph Nader's petitions to be on the presidential ballot. Previously, according to The Times, election officials — on earlier advice from the attorney general's office — had rejected his papers because the papers had not been grouped by congressional districts.

How did the Nader group "get around" the grouping requirement? Here's how: The A.G.'s office said that there was no evidence that the grouping requirement had ever been approved by the Board.

So how can you use this squib in your practice? Never assume that a rule can be used against you just because it's in print. There are a variety of ways to overcome rules. Nader's group used one of those ways: The rule wasn't valid because it had never been validly enacted.

Also, it didn't hurt that Jerry W. Kilgore, the Virginia attorney general, is state chairman for Bush's reelection campaign. The Times, in the last sentence of its article, reports that the A.G.'s spokesman "denied any partisan considerations in [the] reversal."

If you want some local color about the contest and what happened when the Nader people tried to file their petitions, you can go to this report. The report also includes a description about how one Nader worker who was unhappy about not having been paid for his petitions nearly caused a vehicle collision with another Nader worker.

Here's one out-of-the-box way to reduce medical malpractice suits: Reduce the medical malpractice — A new study reports that an average of 195,000 people have died annually due to errors in hospitals

Maybe there's a little-publicized reason for medical malpractice suits: there's way too much medical malpractice.

Health Grades, Inc., an independent healthcare quality company, recently reported that "[a]n average of 195,000 people in the U.S. died due to potentially preventable, in-hospital medical errors in each of the years 2000, 2001 and 2002." A summary of its report of its study of 37 million patient records is included in its news release.

According to Dr. Samantha Collier, Health Grades' vice president of medical affairs, "The equivalent of 390 jumbo jets full of people are dying each year due to likely preventable, in-hospital medical errors, making this one of the leading killers in the U.S."

Again according to Dr. Collier: "If the Center for Disease Control's annual list of leading causes of death included medical errors, it would show up as number six, ahead of diabetes, pneumonia, Alzheimer's disease and renal disease."

Health Grades' full study, published last month (July 2004), cited a 1999 study by the Institute of Medicine (part of the National Academy of Sciences). That IOM study had estimated that "[b]etween 44,000 - 98,000 Americans die from medical errors annually." (I discussed that study in my first medical malpractice posting. The IOM study concluded that "Medical errors kill more people per year than breast cancer, AIDS, or motor vehicle accidents.")

Here, without the footnotes, are the last two paragraphs of the Health Grades study:

"Until . . . best practices are developed, disseminated, and adopted to prevent medical errors and injuries, focused improvement efforts on four key areas - Failure to Rescue, Decubitus Ulcer, Postoperative Sepsis, and Postoperative Pulmonary Embolism or Deep Vein Thrombosis - will significantly improve patient safety in our hospitals and reduce costs. If we focused our efforts among Medicare beneficiaries on these four areas only and were able to reduce excess attributable mortality and costs by just 20%, we would prevent almost 18,000 avoidable deaths and save Medicare and society $380 million in excess inpatient costs annually. The enormity of just 20% of this situation is analogous to turning a deaf ear and blind eye to 35 jumbo jets filled with Medicare beneficiaries crashing each year. This should result in an outcry from every American demanding the right to patient safety in our hospitals.

"In conclusion, our results illustrate and validate previous studies that medical injuries in hospitals continue to be a real threat to Americans and are associated with significant negative economic consequences. Most disturbingly, similar to previous study conclusions, these figures likely represent an underestimation of the true mortality and costs attributable to patient safety incidents within our U.S. health care system. As such, we recommend that more research be done to assess patient outcomes beyond death and costs, to understand circumstances and risk factors associated with medical injuries, and to develop strategies to prevent medical injuries."

The full study of the Institute of Medicine of the National Academy of Sciences is entitled "To Err Is Human: Building a Safer Health System" and may be purchased, downloaded in a pdf format, or even read online at no charge. An eight-page summary of the report can also be downloaded or read online.

IOM had a one-paragraph summary of its 1999 study that expressed optimism about cutting down the death rate:

"This report lays out a comprehensive strategy by which government, health care providers, industry, and consumers can reduce preventable medical errors. Concluding that the know-how already exists to prevent many of these mistakes, the report sets as a minimum goal a 50 percent reduction in errors over the next five years. In its recommendations for reaching this goal, the committee strikes a balance between regulatory and market-based initiatives, and between the roles of professionals and organizations."

Unfortunately, the Health Grades study found that not only had the error rate not decreased, it had, in fact, increased.

The IOM has a number of reports with recommendations for improving patient care and safety. Those reports with IOM's descriptions include:

"Keeping Patients Safe: Transforming the Work Environment of Nurses identifies solutions to problems in hospital, nursing home, and other health care organization work environments that threaten patient safety through their effect on nursing care. The report puts forth a blueprint of actions that all health care organizations which rely on nurses should take."

and

"Patient Safety: Achieving a New Standard for Care provides a detailed plan to facilitate the development of data standards applicable to the collection, coding, and classification of patient safety information. This report addresses key areas related to the establishment of a national health information infrastructure, including: a process for the ongoing promulgation of data standards; the status of current standards-setting activities in health data interchange, terminologies, and medical knowledge representation; as well as the need for comprehensive patient safety programs in health care organizations."

It's obvious that there is malpractice and that thousands upon thousands of people die in hospitals as a result. And the figures from IOM and Health Grades do not even include people who die as a result of medical negligence that occurs not in hospitals but in doctors' offices away from hospitals. Moreover, the IOM and Health Grades figures only include deaths and do not include tragedies such as patients whose wrong arm, leg, lung or other part of their body has been amputated or removed. Perhaps more attention should be paid to delivering safer health care instead of blaming the attorneys who file the lawsuits on behalf of the victims and the survivors of the victims.

For instance, in the delivery of health care, how many times have patients been given the wrong medication or the wrong dosage because a pharmacist could not read a physician's handwriting. In order to prevent these misreadings, perhaps all states should require, as Florida does, that all prescriptions that physicians write must be "legibly printed or typed so as to be capable of being understood by the pharmacist filling the prescription." Florida statutes, Section 456.42. So obvious a solution, but so little has been done to enact that type of statute nationwide.

Stay tuned to this blog for a third posting on medical malpractice, maybe on the handwriting problem. In the meantime, you might take a look at a newspaper article that cited a study that found that about 6 percent of U.S. hospital patients hurt by medication could be linked to bad handwriting.

ADDENDUM:

The Health Grades study also included in its report what it rated as the "best" hospitals for safety and costs.

ADDENDUM NUMBER 2:

There are, of course, critics of the study. For instance, one article discusses some of that criticism. One of the physicians who is quoted is Robert M. Wachter, "a professor in the Department of Medicine at UC San Francisco and the author of a well-respected book on medical errors, Internal Bleeding: The Truth Behind America's Terrifying Epidemic of Medical Mistakes." (If you want to learn a lot about what Dr. Wachter calls the "Terrifying Epidemic," take a look at his book.) According to the article, Dr. Wachter says the Health Grades study is "flawed in some truly fundamental ways." However, the article also points out that both Dr. Collier (of Health Grades) and Dr. Wachter "acknowledged that there was no reliable way to truly know how many people die each year from medical errors, and Wachter acknowledged that the figure could well be as high as 200,000 a year."

LINKS:

For those who receive a printed version of this posting:

Health Grades' press release is at http://www.healthgrades.com/public/index.cfm?fuseaction=mod&modtype=content&modact=Media_PressRelease_Detail&&press_id=135. Its full study is at http://www.healthgrades.com/media/english/pdf/HG_Patient_Safety_Study_Final.pdf.

The summary of the IOM estimate of from 44,000 to 98,000 deaths is at http://www.iom.edu/subpage.asp?id=14980.

My first posting on medical malpractice is at http://www.outoftheboxlawyering.com/archives/000042.html.

The IOM report may be purchased at http://www.iom.edu/report.asp?id=5575 and its eight-page summary may be downloaded at http://www.iom.edu/file.asp?id=4117.

The IOM's reports with recommendations for improving patient care and safety are at http://www.iom.edu/focuson.asp?id=8089.

Florida's statute may be found at http://www.flsenate.gov/Statutes/index.cfm?App_mode=Display_Statute&Search_String=&URL=Ch0456/SEC42.HTM&Title=->2004->Ch0456->Section%2042#0456.42.

The newspaper article on handwriting and Florida's solution is at http://www.sptimes.com/2003/08/02/State/Clearly_curing_the_co.shtml.

The article quoting Dr. Wachter is at http://www.eweek.com/article2/0,1759,1631136,00.asp.

Out-of-the-box ways to use Google: How to find more than just the normal web site information using Google

TIPS, TOOLS AND TECHNIQUES FOR FINDING VALUABLE INFORMATION WITH GOOGLE by Adolph J. Levy 518 S. Rampart Street New Orleans, LA Copyright Adolph J. Levy 2003 – 2004 SUMMARY

This article discusses some of the known and the mostly unknown ways that you can use Google. For instance, did you know you can:

1. Use Google to convert to and from metric measurements, such as, for instance, "What is 100º Fahrenheit in Celsius?"

2. Instruct Google to search for synonyms of your search word – without typing all of the synonyms. Just place a ~ (tilde) without a space, immediately in front of the word.

3. Use Google as a spell checker.

4. Find definitions of words – and links to sites where the words are defined.

5. Track your UPS and Fed Ex mailings.

6. Search for Power Point Presentations on your topic of interest.

7. Translate web pages from foreign languages.

8. Find photographs and drawings – such as medical photos and illustrations.

And, like the Ginzu knife commercial, there's more. And more. And more. . . .

The Details

I. Google Searching — using the Google search bar

A. Use quotation marks when searching for phrases – It can help place best results at the top of the results and reduce your irrelevant results. For instance, use quotation marks to type "New Orleans" as a phrase.

Also use the quotation marks to search for a quotation, the name of a book, etc.

B. Too many results? You can place a minus sign in front of a word to exclude entries with that word. If you are searching for "saints" for a list of saints, you can eliminate the football team by entering -football in the entry bar. (Don't include a space between the minus sign and the first letter of the word.)

To make certain that a word is included in your search results, place a plus sign in front of the first letter of the word.

C. You can "Search within results" by entering additional words at the bottom of the results page or by adding the words in the search bar.

D. When you search for factual information, you can try two techniques:

1. Enter your search as a question: How long was Noah's ark; or

2. Enter your search as a statement in a way that a writer would state it: Noah's ark was cubits long.

(You will find the ark was to be 300 cubits long, 50 cubits wide and 30 cubits high. How long is a cubit? Google will tell you. I'll show you how to find out below.)

E. If you want to expand your search by adding alternative words in your search, Google has a command that tells Google to search for synonyms. To use it, place a ~ (a tilde) in front of the words that you want to have Google automatically search for synonyms. Thus, ~attorney would search for attorney as well as lawyer.

F. Use the "cache" on Google's results if you click on Google's search result for an item and can't get connected to the linked page.

G. Do you have a telephone number on a slip of paper and don't know whose number it? Use Google. Just type in the number with the area code.

H. Want to convert from Fahrenheit to Celsius or solve some other math problem or question? Just type the question in the Google search bar.

Ex.: What is 100 degrees Celsius in Fahrenheit?
Ex.: What is 300 cubits in feet? (Google says that's 450 feet, so Noah's Ark was 450 feet long. There is some debate about the real length. See http://www.flood-myth.com/ark.htm. But that debate is for others and for another time.)

Ex: What is 25 in binary?

I. Don't know how to spell something? Use Google as a spell checker. If the word is misspelled, you may get this response from Google: "Did you mean:" with Google supplying the proper spelling. (If the word is commonly misspelled, you may not get the warning about the misspelling.)

Try typing "100 degrees Celsius in Fahrenheit" (without the quotes) and see what happens.

J. Want to find the status of an airline flight? Type the airline and the flight number. For instance, Delta 44.

K. Want to find a stock quote? Type stock:aapl or stock:msft (no spaces)

L. Do you have a bar code but the manufacturer's name is no longer on the product? Just enter the bar code including the beginning and ending numbers of the bar code: 722868180631.

M. Want a telephone number? For a United States resident, type first name (or first initial), last name, city (state is optional). You can also try:

first name (or first initial), last name, state
first name (or first initial), last name, area code
first name (or first initial), last name, zip code
last name, city, state
last name, zip code

(You may not always get a result, but you can't beat the price.)

For a business telephone number, type bphonebook:name of company, city state (or type the name of the business and its zip code.)

N. Need to define a word and find online sources for the definition? Type: "define:" followed by the word (type the colon but not the quotes).

For instance, try define:voip or define:idiopathic or define:"therapeutic jurisprudence" (again, no spaces after the colon). And try define:iatrogenic.

O. Want to find where a location is on a map? Type the address (including the city and state), and you will probably be directed to a map showing the location. Google will give you a direct link to a map showing your location on Yahoo's Maps or on MapQuest.

P. Do you want to find information about a vehicle but all you have is its VIN number? Just enter the VIN number and you will probably see a link to www.carfax.com. I entered a VIN number for a car I drive, and was shown the following at no charge:

VIN:
Year/Make/Model:
Body Style:
Engine Type:
Manufactured In:

In addition, the Carfax site (www.carfax.com) reflected that three records for that VIN number were in its database. Although the records were not set forth in detail, they could be seen for a fee. The site also included some additional data, such as safety and reliability reports and a more detailed vehicle history, all of which could also be seen for an additional fee.

If you have a case involving a vehicle, you will probably be able to find the names of prior owners of the vehicle, when the vehicle had been previously sold, and the odometer readings at the time of the sales.

You may also find manufacturer recalls and other information.

Q. Here are some other number-related searches that you can do. You can search using:

1. UPS tracking numbers
2. FedEx tracking numbers
3. USPS tracking numbers
4. Patent numbers
5. FAA airplane registration numbers
6. FCC equipment IDs

To see a list of Google's number-related searching facilities and the formats for using those facilities, go to Google's main page, click on Advanced Search, then on Advanced Search Tips, then on Google features, and finally on Search by Number. (All of these examples and instructions and the others described in this outline are, of course, subject to change).

R. Do you want to get a more sophisticated in your searching? Use "Advanced Search" on the main Google search page:

1. You can specify the portions of the web page you want to search, such as

a. Intitle:
b. Inurl:

2. You can limit the search to the past three months, six months, or one year.

But note that Google's web search may not function as you might expect because the dates that Google uses might be the dates when Google's robot last updated the web page. However, the date search may work for searches in Google's Groups and in Google's News. Sometimes if you get too many results, you might try including an appropriate year in your search, such as 2002 if you are searching for something from that year. This could eliminate some valid hits, but it could also narrow down your results.

(You can also limit the search to a particular date range by using Julian dates, but that is too complicated for me to explain, assuming I really knew how to do it. But you can use www.faganfinder.com , which I cite below.)

3. Want to get your results from only universities or from governments? You can limit your search to a particular domain (.edu or .gov) or to a particular site.

4. Do you want to find only PowerPoint presentations? Go to File Format, use the drop-down list, and click on Microsoft PowerPoint. It's the same procedure if you only want to find Acrobat pdf files or Excel spreadsheets.

Using this technique is a good way to find cutting-edge information. You might find someone's PowerPoint presentation even before there are detailed articles on a topic.

You can also use this technique to find experts who are giving presentations on a topic that interests you. For instance search for HIPPA and select file format Microsoft PowerPoint.

(If you don't have PowerPoint on your computer, you may get an error message when you try to load the presentation. However, you can download without charge a PowerPoint reader from Microsoft's website. The current link for the download is:

http://www.microsoft.com/downloads/results.aspx?productID=B157E6F3-5AF9-48CB-A153-895C1AA220F8&freetext=&DisplayLang=en)

5. For more information about Advanced Search, click on "Advanced search tips."

S. Use "Preferences" on the main Google search page

1. You can change the language of your search page. Try Icelandic or even Pig Latin.

2. You can change how many results are listed on your screen. Try 25 or 50 instead of the 10 that is the default number.

3. You can open the results in a new window.

T. Click on "Language tools" on the main Google search page:

1. You can translate web pages that are in foreign languages.

2. You can use Google to translate words or other material to and from English. The available languages for translation are German, Italian, French to and from English, and Portugese and Spanish to and from English.

U. Images

Do you need a drawing or a picture or a photograph? Search Images on the main page. Try "heart attack" or "St. Louis Cathedral," "New Orleans," or Billy the Kid."

Using Images is a great way to find demonstrative aids, but don't forget about copyright laws.

(You can also limit your Image searches, to, for instance, .edu or .gov sites).

V. Groups

This is one of the least-known but most valuable sources of information on Google. You can use it to discover what people have been saying about a product or virtually anything else that has been discussed in certain public discussion groups. Google notes that "Google Groups contains the entire archive of Usenet discussion groups dating back to 1981."

If you know someone's e-mail address, you can even search for what that person has posted to public areas using that address.

Use groups, for instance, if you are interested in buying a product, if you have a computer error, or for virtually anything.

You can also use Groups to see if others have had the same problems with a product that you or your clients are having. You may also be able to learn how others have solved their problems.

W. Directory

Google has some items that have been categorized by real people. You can search by category, but not all items are categorized.

X. News

See the latest news for the last 30 days from approximately 4500 news sources. You can do a normal Google search for the latest news.

Looking only for press releases? Try entering a product or a manufacturer and add "Press release" (without the quotes).

Incidentally, did you know the news stories and the headlines are not selected by humans? Google says the stories are selected and the headlines are written by computer.

Y. News Alerts

This could be extremely valuable. Want to see every time that a company is mentioned in one of those 4500 news sources? Or do you have a product or a person that you want to track? Google can automatically send notices to you each time your selection is mentioned. You can also choose to receive a daily summary. AND IT'S FREE. Click on "News Alerts" on the News page and you can sign up for up to five free news alerts.

II. The Google Toolbar

This is a Google freebie that can be invaluable. You can download the Google toolbar to place at the top of your screen and you can use it for a variety of functions.

Click on "more" at the top of the Google search screen and you will see a link to "Google Toolbar." Here's some of what you can get if you download it:

A. You will be able to do a Google search from anywhere in your browser. You won't have to load the Google page.

B. It will eliminate pop-up ads (according to Google). And it will tell you how many pop-ups it has blocked.

C. Here's are two ways that the toolbar can help you in your searching:

1. Have you ever clicked on a link from a Google search and couldn't find the words you were searching for in the linked pages? The Toolbar includes each of your search words. You can click on each of the words and go directly to the word in the site. You don't have to read the entire site to see the word. (It doesn't always work, but it does most of the time.) You will then be able to find your search terms without reading the entire page that you found.

2. You can turn on a highlight button and all your search terms will be highlighted in your search results. You can turn the highlight on and off by clicking on the icon that looks like the nib of a fountain pen. (Remember fountain pens? Or are you too young to know what they are?)

III. Adwords

A. When you do a search, you will see small block ads on the right side of the page. (Google calls these "Sponsored Links"). They relate to the search words you used in your search. If you have a website, you can have your firm come up in an ad. And you pay only if someone clicks on your ad to go to your site. The price per click depends on how many people want to use the word in an ad and you can set the maximum amount you get billed for.

B. To see the rules and instructions, type "adwords" in the main Google search bar.

IV. Froogle

A. Do you want prices and locations for buying products? Try http://froogle.google.com/ (Note there is no www.)

B. Google notes: "As with all other Google search results, Froogle ranks store sites based only on their relevance to the search terms you've entered. Google does not accept payment for placement within our actual search results, and advertising that appears to the right of Froogle search results is always clearly identified with the label ‘Sponsored Links.' "

V. Here are two sites that may allow you easier ways to search Google

A. www.soople.com This places on one screen many of Google's search allows facilities. You might find it even easier to use than Google itself. Soople also you to easily search for movie reviews.

B. www.faganfinder.com This one allows you to search by date. Click on http://www.faganfinder.com/google.html (The dates that the site uses as a reference may sometimes be the date when Google last indexed the site.)

The sites also have some search capabilities that Google itself doesn't have.

VI. Additional references

A. For an excellent Google manual that's written in plain English, get "How To Do Everything With Google." It has a 2004 copyright date and is written by three Google employees. The list price is $24.99.

B. Another book that lists a lot of Google uses is "Google Hacks: 100 Industrial-Strength Tips and Tools" by Calishain and Dornfest. It's $24.95 retail. Some of the book is for programmers, which I am not. But there's a lot of material for users who aren't programmers.

C. Google labs. Http://labs.google.com. (Note: there is no www.) "Google's technology playground. Google labs showcases a few of our favorite ideas that aren't quite ready for prime time."

D. Google services and tools. http://www.google.com/options/. "Google has many special services and tools to help you to find exactly what you're looking for."

VII. Miscellaneous

A. Google has a newsletter to keep you up to date on what they're doing at Google. Go to the Google search screen and type "Google friends newsletter" (without the quotes). (As of July 2004, the last issue was in March 2004.)

B. Have some kitchen leftovers? Type in what you have and you will get recipes that use those ingredients.

C. Want to get a list of the most popular Google searches for the past month and for other periods — and for a number of different countries? Go to http://www.google.com/press/zeitgeist.html.