Tag Archives: ministry of health

To Medically Err Is Human; Pointing A Futile Finger

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Give me a month. Any given month, just one month without a horror story, give me a month in which no one makes a medical error, one month in which we don’t hear about some person’s horror story at the hands of evil doctors and the henchmen in nurse’s outfits.

Chances are you can’t, because there aren’t any. Medical errors are seemingly inevitable, they have to happen, just like car accidents and farting in public, mistakes happen. They are part and parcel of having healthcare. After all; unlike the airline industry and the people who make the iphone we don’t really have a blueprint or a service manual.

This is why I’m using the bible of all medical error literature to date – and the keystone of America’s healthcare revolution – to prove my point. The U.S. Institute of Medicine white paper entitled “To Err is Human ….” estimates that between 44,000 and 98,000 people die from medical errors in the US annually. That’s more than the people heart attacks and strokes combined kill in Kuwait and is more than those who are killed by breast cancer in the US.

Having said that the study was written in 1999 and the number would probably be three times as high this year if it weren’t for the boffins who wrote the document and forced people to follow it.

There’s another reason why I chose this study, it’s because we have the same problem as the US. We have lots of doctors, lots of hospitals/practices and not enough oversight (three exams make you registered to practice, 2 more make you a specialist in the US and you can do all five without looking at a patient) so I figured their answer would be ours. After all, we’ve imported everything from ketchup to coffee chains and managed to make them work, might as well do the same for policy; besides we know it works because they’ve managed to reduce medical errors to about 10% of the original number over ten years.

The study looked into every major medical error, every big lawsuit and settlement and every single post mortem they could find and came up with the following:

  • They found that medical errors occur in three stages: failure to diagnose (wrong tests, wrong timing of tests, old and redundant tests), failure in treatment(delay in treatment, lack of drugs, technical error during a procedure) and failure in prevention (lack of patient follow-up, lack of foresight given patients current condition)
  • Creating a nationwide program for leadership, research, tools, and protocols to enhance the knowledge base about safety and patient awareness. In other words, integrating administration into day to day healthcare and making it part and parcel of the practice of medicine.
  • Developing a nationwide public mandatory reporting system and by encouraging health care organi¬≠zations and practitioners to develop and participate in voluntary reporting systems meaning that you need to report any problems you face without being blamed for them directly and providing the manpower required to piece together the sequence of the events that lead to the problem.
  • Providing standards to adhere to and aspire to within each branch of healthcare. As it stands we don’t provide doctors with job descriptions when they are hired, only a set of arbitrary rules.
  • Putting in place safety systems in health care organizations to ensure safe practices at the delivery level.

The point I’m trying to make with this whole post is the fact that in all of the above not a single doctor/nurse/security guard was beaten, sued or had his license stripped. If anything the strategy outlined tell you to go back and hold yourself accountable for what you’ve done and find out where you went wrong and how to fix it then share what you’ve learnt with the people you work with so that the same mistake doesn’t happen again.

I am quick to point out however that the study doesn’t condone negligence in which someone has made a deliberate error that they should not have (i.e. cutting a nerve because it simplifies the surgery or giving a patient an overdose so that they sleep and leave you alone for the night only to find them not breathing in the morning).

So perhaps the newspaper stories, TV interviews and patient export program may not be quiet as effective (or affective ….still can’t tell the difference) as teaching medical students and doctors in training to review medications they’ve given and procedures they’ve performed and sharing their experiences with their colleagues………

Oh well …I’m not holding my breath…

The Study mentioned can be found on Google books but be for-warned it’s about 300 pages long …….