Filed under: practice | Tags: doctor, errors, health care, medical errors, medical mistakes, physician, reporting
Medical errors happen. That’s just a fact. However, not all medical errors have to happen. Despite what we know about such incidences, we may know very little. At least one study shows that while the vast majority of health care providers agree that reporting medical errors will improve health care delivery, only a minority of doctors actually report their errors (see article).
According to the study, conducted by Lauris Kaldjian, M.D., Ph.D., associate professor of internal medicine at the University of Iowa Carver College of Medicine:
“The answer to the gap may lie partly in other findings from the survey, he noted: Only 55 percent of the respondents knew how to report errors, and only 39 percent knew what kinds of errors to report.”
Another study confirms that health care organizations often have poor error reporting systems, leading physicians to “depend on discussions with colleagues rather than reporting to the hospital or health organization, and important information regarding medical errors and prevention is lost.”
Another explanation offered is that the culture of the health care industry and the stigma tattooed onto those who make such errors discourages providers from reporting their mistakes. Even though errors may be the fault of a system or process, as opposed to the individual, blame often lies with the provider.
Whatever the reason(s) may be, it’s clear that not reporting errors is a significant problem. Fair or not, doctors are held to a higher standard of practice than most professionals. Still, over a career, it is likely that most, if not all, physicians will make a mistake in treating their patients. But wouldn’t it be wise to have a system that allows doctors to learn from those errors rather than to hide or try to forget them?
Filed under: medicine, practice, Uncategorized | Tags: errors, health care, healthcare, healthcare systems, medical, medical errors, medical mistakes, reporting, system
Humans are imperfect, thus their actions are expected to be as well. However, in healthcare, medical errors, quite often, are the result of a breakdown in macro- and micro-systems; not necesarily the individual caregiver. Errors in healthcare are, in many instances, symptoms of systemic problems. Yet it’s not uncommon for individuals to shoulder the blame versus a deeper investigation of the system/process inside which an error was made. Let’s be honest, it’s easier and quicker that way.
Under this approach, hospitals can isolate the source (caregiver) of the error, respond quickly and move on.
But why did the error occur? Maybe the equipment is outdated, a poor records management system, not enough support staff, too many hands in the process, inadequate training, lack of protocol, etc.
When blame is unfairly cast, it’s no wonder doctors do not report all incidences…
Filed under: medicine, practice | Tags: errors, healthcare, medical mistakes, mistakes
Perhaps more than any other profession, healthcare practitioners give of themselves for the benefit of the greater public. Mistakes are inevitable any time you place humans in complex systems with many moving parts, heavy workloads and the necessity for great informational recall.
Still, the number and frequency of medical mistakes cannot be overstated or harped on enough. Here is a brief synopsis of statistics on the commonality of medical mistakes.
(On the flip-side, Forbes.com offers a slideshow of their picks for the safest hospitals in the U.S.)
What likely adds to this predicament is the lack of reporting, and thus accountability, when mistakes are made…
Filed under: medicine, practice | Tags: healthcare, heroin, medicine, morphine, pain medication
True story: A patient limps into an Arizona State University health center for a follow-up appointment after being hit by a car while riding his bike. The injury the patient sustained to the left knee wasn’t healing well and needed a doctor’s evaluation.
“I thought you were just coming in for more pain medication,” said the doctor before even examining the knee. By the end of the evaluation, the doctor recognized here erred judgement and urged the patient to go to the ED at a nearby hospital because the injury had worsened since the initial exam. She felt the injury required more comprehensive and urgent attention than she was able to provide.
When did doctor’s start accusing new patients of being drug-seekers before examining them? Logically, it seems that one should demonstrate a certain behavior before being accused of it. Considering the purpose of the appointment, it truly added insult to injury.
For historical context, prior to the 1924 ban of narcotic sales by the U.S. Treasury Dept., heroin, morphine and cocaine could be found at the corner drugstore, next to the licorice and tobacco. Or, they could be mail-ordered through catalogues, complete with syringes.
According to Robert Youngson in Scientific Blunders: A Brief History of How Wrong Scientists Can Sometimes Be, the widespread availability and use of poorly understood drugs led to the addiction of over 400,000 soldiers during the Civil War, and the number of addicts in the general population was wider still.
Today, despite a vastly greater body of knowledge of these drugs, proper uses and possible dangers, narcotic abuse continues. Understandably, prescribers are cautious. Yet, statistically, the number of individuals addicted to narcotic pain medication is vastly outweighed by those who’ve benefited therapuetically through appropriate usage.
How often do healthcare providers assume a patient is a drug-seeker? How does that assumption affect the care they give that patient? How often are they wrong?
Filed under: practice | Tags: hand sanitation, hand washing, healthcare, infection, sink, washing
Healthcare practitioners perform amazing feats every day. They transplant organs, cure cancer and revive hearts that have stopped beating.
One task they do not perform consistently is washing their hands. Sinks are plentiful and the benefits of proper hand hygiene are widely known, yet research shows that healthcare practitioners wash their hands less than 10% as often as they should.
Healthcare providers list inconvenient sink locations, lack of supplies, lack of time, dry hands and forgetfulness as primary reasons for the industry’s abysmal handwashing compliance.
Research has clearly shown that proper hand sanitation reduces the spread of healthcare-associated infections (HAI). So, what is the cost of poor hand sanitation?
Some insurance providers have stopped paying for the treatment of certain HAIs knowing that they were likely cause by poor hand sanitation.
Aside from the financial, resource and health costs associated with treating these infections, the CDC reports almost 2 million HAIs each year in the U.S. Of those infected, roughly 100,000 die. In fact, as many patients die from these infections “as from AIDS, breast cancer, and auto accidents combined,” according to the Committee to Reduce Infection Deaths.
Knowing the consequences on human life alone, does any excuse for not washing one’s hands really hold water?
Filed under: practice | Tags: billing, insurance, medical mistakes, mistakes, never events, surgery
Every year, in the U.S. alone, an estimated 1,300-2,700 patients are unnecesarily killed, maimed or injured as a result of ”never events” – inexcusable medical errors that should never happen. Examples include operating on the wrong patient or the wrong body part (see comprehensive list, from the National Quality Forum).
In 2007, major media outlets ran an AP story reporting that three wrong-site brain surgeries were performed at Rhode Island Hospital that year. For the mistakes, the hospital was basically given a demerit by the Department of Health and fined $50,000.
As though the additional complications, pain and recovery time from unnecessary medical procedures wasn’t bad enough, until recently, many medical facilities still billed patients and insurance companies for the erroneous procedures. (I wonder if the three patients at Rhode Island Hospital were billed for the surgical mistakes. And if so, did those charges exceed the hospital’s $50,000 fine?)
How difficult is it for surgeons or caregivers to take a marker and write “this shoulder” or “this kidney” on a patient? And while many hospitals are changing their billing policy when it comes to never events, how did they ever justify charging these patients in the first place?
Addition: For a brief slideshow of preventable hospital complications, take a look.
