Recently, I attended a lecture by an eminent professor who spoke about medical errors and its impact on not only the patients but also the doctors & healthcare professionals who treat them.
The topic of Medical Errors is an important & interesting one, which was brought to the forefront after the report ”To Err Is Human” from the Institute of Medicine in the USA in 1999, which highlighted the alarmingly high mortality rate & cost of adverse events.
Doctors, nurses & other healthcare professional do not go to work everyday with the intent to kill/maim/injure their patients. We are not God (although some may believe & behave like they are), and human error is inevitable. It is a fact of life. Misdiagnoses, missed diagnoses, mis-treatment, omissions of treatment all happen. Is it avoidable? Absolutely.
A huge first step needs to be taken in changing the climate of fear that surrounds every medical error that happens now. The first reaction (after correcting or attempting to correct it) is usually one of how to cover up the fact that the error had ever occurred in the first place. There is usually a blame fest that surrounds such an error, with fingers pointing every which way. This culture of blame needs to change within the medical community, first, before systems & processes can be put in place to address the problem. Without the fear of punitive action, people would be more willing to identify errors or near misses. After all, if you don’t know where the problem lies, how will you correct it? Currently, who would dare to report the problem for fear of being blamed for the problem in the first place. A vicious cycle, eh? And how would the person who made the error feel? Pretty damned awful.
Now, what systems am I referring to, you may wonder. An excellent example that was given by an expert on patient safety is that of the ATM machine. Previously, people would often leave their ATM cards in the machine after withdrawing their money. So a system was put place whereby the machine would alert the user (with an incessant beeping) to retrieve his card from the slot before issuing the cash withdrawal & receipt. It is almost impossible for the user to leave his card there now, as the machine WOULD NOT proceed with the transaction until the card had been retrieved.
The aviation industry has improved by leaps and bounds as far as safety is concerned, and is often used as the gold standard. So why can’t similar systems be put in place in the healthcare world to minimize risk of errors? In fact, many healthcare facilities in the USA, the UK and Australia have done so with encouraging results.
Here’s a little factoid for you to mull over: the chance of you dying from a medical error in a hospital is higher than you dying in a plane crash or from a nuclear accident. That is to say, being a patient in a hospital is more dangerous than flying in an airplane or working in a nuclear plant – think about it…
It’s time to start making changes, and accept/admit the fact that mistakes do happen in the practice of medicine. We are, human, after all.