Sunday, October 16, 2005

We ARE Human After All

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.

9 comments:

distinguished mediocrity said...

in my humble opinion, the biggest impedimet to full disclosure and acknowledgement of errors is the constant threat of litigation.

i don't mind admitting that i was wrong, but if by doing so i risk losing everything i own PLUS my license to practise, then i'm certainly going to be thinking more than twice before i do so.

much much more than just twice.

aliendoc said...

and a totally understandable reaction it is - probably most docs would feel the same way. Do a google on patient safety - you'll find that medical errors do not neccessarily equate to medical negligence. Unfortunately, the current culture is such that there is a fear of reporting such errors. But if you don't know what is wrong, how do you fix it? Hence the never-ending cycle until someone "on top" takes a stand...

JJ said...

Well i have to concur that the threat of lawsuits filed by someone who wants a settlement is most likely if a doctor would therefore admit his mistake that would have cost a life.

But i think negligence would be the most common accusation.
Ironical that the person who should save lives are put in such a tight spot

aliendoc said...

all the more reason why systems & processes should be put in place to prevent these errors & alert the doctors before they happen. Doctors do not make mistakes intentionally...but being human, other factors come into play eg. distractions, heavy patient load, sleep deprivation etc etc.

Anonymous said...

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.

The above statement seems contradictory...what is your position? Are we human and therefore errors are "inevitable", or is it "Absolutely" avoidable. Indicating that it is all avoidable promotes the myth of infallibility that starts the finger pointing when LIFE HAPPENS and someone dies or has a bad outcome.

Are there errors? Sure. Are many of them avoidable? Absolutely! Are ALL of them avoidable? ABSOLUTELY NOT.

EW
Washington, United States.

aliendoc said...

"Are there errors? Sure. Are many of them avoidable? Absolutely! Are ALL of them avoidable? ABSOLUTELY NOT."

My point exactly. Apologies if it didn't come across clearly enough. We ARE human & like it or not, mistakes happen. Can we avoid these mistakes, yes we can, maybe not all, but with the right systems in place, many of these mistakes are avoidable. It will take time & a lot of effort before we can reach the safety levels of the aviation industry...

Marvin said...

Perhaps you could elaborate on some changes that you propose would help the system?

The only change I could think of that would make a significant enough impact to rival that of the ATM machine’s analogy, would be if a senior mentor was put on the “front lines” in the ward with the juniors.

But the likelihood of that happening is probably equivalent to my consultant offering to do my changes for me. Not enough drs.

aliendoc said...

Not all systems involve increasing manpower (though obviously, that would be great!). Something as simple as changing the colour of the medication charts from green to red for patients with drug allergies (those red DRUG ALLERGY stickers tend to be overlooked especially by harrased HOs or MOs) would help; with today's technology, the use of electronic prescription would also minimise risk of medication errors.

There are entire organisations dedicated to the improvement of patient safety (google search 'patient safety'). You can find out more from their websites...

Marvin said...

Thanks… I never realized that patient safety agencies existed. Will plough the info in earnest preparation for the day in the bright and very distant future, if ever I make it to CEO. :D