Comments on: Is reducing medical errors similar to improving transportation safety? http://www.kevinmd.com/blog/2009/08/is-reducing-medical-errors-similar-to-improving-transportation-safety.html Tue, 14 Feb 2012 23:00:00 +0000 hourly 1 By: Whttp://www.kevinmd.com/blog/2009/08/is-reducing-medical-errors-similar-to-improving-transportation-safety.html#comment-109787 W Wed, 19 Aug 2009 11:10:32 +0000 http://www.kevinmd.com/blog/?p=39573#comment-109787 If something does go wrong, at least in a large clinic setting, who decides how to respond -- the medical staff directly involved, or the risk management attorneys (who weren't there, have limited if any medical knowledge, and are duty-bound to employ all means necessary to prevent potential judgments against the clinic, whether a lawsuit has been filed or not)?This is why I don't blame doctors. Unless you're private practice, I just don't think you have that much control. If something does go wrong, at least in a large clinic setting, who decides how to respond — the medical staff directly involved, or the risk management attorneys (who weren’t there, have limited if any medical knowledge, and are duty-bound to employ all means necessary to prevent potential judgments against the clinic, whether a lawsuit has been filed or not)?

This is why I don’t blame doctors. Unless you’re private practice, I just don’t think you have that much control.

]]> By: Mikehttp://www.kevinmd.com/blog/2009/08/is-reducing-medical-errors-similar-to-improving-transportation-safety.html#comment-109753 Mike Wed, 19 Aug 2009 01:41:39 +0000 http://www.kevinmd.com/blog/?p=39573#comment-109753 A medical mistake is if you amputate the wrong arm or leg, or if you remove the wrong breast, or if you administer the wrong drug or dose.A medical error is not a known complication of a procedure or hospitalization. Ventilator acquired pneumonia, sacral decubitus ulcers, Foley catheter infections, deep vein thromboses are not 100 percent preventable. So to NEVER PAY FOR THEM is offensive. A medical mistake is if you amputate the wrong arm or leg, or if you remove the wrong breast, or if you administer the wrong drug or dose.

A medical error is not a known complication of a procedure or hospitalization. Ventilator acquired pneumonia, sacral decubitus ulcers, Foley catheter infections, deep vein thromboses are not 100 percent preventable. So to NEVER PAY FOR THEM is offensive.

]]> By: jengahttp://www.kevinmd.com/blog/2009/08/is-reducing-medical-errors-similar-to-improving-transportation-safety.html#comment-109738 jenga Tue, 18 Aug 2009 22:46:44 +0000 http://www.kevinmd.com/blog/?p=39573#comment-109738 Unintended consequences Don't pay for catheter related infections, guess what hospitals ban indwelling foleys and if you are sick you get the priviledge of lying in your own piss. Our government at it's finest. Unintended consequences
Don’t pay for catheter related infections, guess what hospitals ban indwelling foleys and if you are sick you get the priviledge of lying in your own piss. Our government at it’s finest.

]]> By: anonhttp://www.kevinmd.com/blog/2009/08/is-reducing-medical-errors-similar-to-improving-transportation-safety.html#comment-109710 anon Tue, 18 Aug 2009 20:07:47 +0000 http://www.kevinmd.com/blog/?p=39573#comment-109710 Compare medicine to aviation and transportation when this is considered routine:http://micom.net/oops/AirMaint.jpg Compare medicine to aviation and transportation when this is considered routine:

http://micom.net/oops/AirMaint.jpg

]]> By: Rezmed09http://www.kevinmd.com/blog/2009/08/is-reducing-medical-errors-similar-to-improving-transportation-safety.html#comment-109697 Rezmed09 Tue, 18 Aug 2009 18:18:22 +0000 http://www.kevinmd.com/blog/?p=39573#comment-109697 How about limiting work hours for docs like the FAA does with pilots?As far as I can tell, pilots only fly one plane at a time, aren't threatened with lawsuits while flying, aren't talking to insurance companies while flying, and aren't being told to fly a plane that should be grounded. How about limiting work hours for docs like the FAA does with pilots?

As far as I can tell, pilots only fly one plane at a time, aren’t threatened with lawsuits while flying, aren’t talking to insurance companies while flying, and aren’t being told to fly a plane that should be grounded.

]]> By: Chuck Brookshttp://www.kevinmd.com/blog/2009/08/is-reducing-medical-errors-similar-to-improving-transportation-safety.html#comment-109696 Chuck Brooks Tue, 18 Aug 2009 17:59:56 +0000 http://www.kevinmd.com/blog/?p=39573#comment-109696 This is why the phrase 'practice of medicine' is appropriate, and for the same reason as 'practice of law' is accurate in that field of activity. If either of these things were deterministic then there would be no need for doctors or lawyers, among other things. Chuck Brooks FutureWare SCG This is why the phrase ‘practice of medicine’ is appropriate, and for the same reason as ‘practice of law’ is accurate in that field of activity. If either of these things were deterministic then there would be no need for doctors or lawyers, among other things.
Chuck Brooks
FutureWare SCG

]]> By: Supremacy Claushttp://www.kevinmd.com/blog/2009/08/is-reducing-medical-errors-similar-to-improving-transportation-safety.html#comment-109695 Supremacy Claus Tue, 18 Aug 2009 17:51:41 +0000 http://www.kevinmd.com/blog/?p=39573#comment-109695 The never events are not medical errors, they are pretextual government oppression, intimidation, and attempt to weasel out of payments due.There are real medical errors, and they are like air crashes.First, they do not have a chain of causation, a Medieval superstition to which the courts still adhere. Like air crashes, a cluster of factors comes together at a single place and time. The average may be 12. Each is required for the disaster to take place.Second, the deletion or prevention of only one or two may prevent the entire disaster.Third, reduction of disasters may be achieved by a change in the system to address the 12 factors. In Demming, the unit could be closed until the factors are found, and the system is changed.This modern view of disaster makes all medical malpractice claims based on superstition, like saying, devils did it or a curse has been placed on the victim. Furthermore, the pursuit of single scapegoats precludes and delays prevention. The fear of institution ending litigation also causes a deep cover up.As a patient, I am willing to not sue if the administration will rush from home at midnight to get as many facts as possible after I am injured by a medical mistake. Change the system, and publish the results of the investigation to the web. Others may institute system changes without having to hurt a patient first. I know that any settlement comes from the care of other patients, and that no money will restore me. I also know that the coverup will insure that many others suffers the same injury from covered up medical errors. The never events are not medical errors, they are pretextual government oppression, intimidation, and attempt to weasel out of payments due.

There are real medical errors, and they are like air crashes.

First, they do not have a chain of causation, a Medieval superstition to which the courts still adhere. Like air crashes, a cluster of factors comes together at a single place and time. The average may be 12. Each is required for the disaster to take place.

Second, the deletion or prevention of only one or two may prevent the entire disaster.

Third, reduction of disasters may be achieved by a change in the system to address the 12 factors. In Demming, the unit could be closed until the factors are found, and the system is changed.

This modern view of disaster makes all medical malpractice claims based on superstition, like saying, devils did it or a curse has been placed on the victim. Furthermore, the pursuit of single scapegoats precludes and delays prevention. The fear of institution ending litigation also causes a deep cover up.

As a patient, I am willing to not sue if the administration will rush from home at midnight to get as many facts as possible after I am injured by a medical mistake. Change the system, and publish the results of the investigation to the web. Others may institute system changes without having to hurt a patient first. I know that any settlement comes from the care of other patients, and that no money will restore me. I also know that the coverup will insure that many others suffers the same injury from covered up medical errors.

]]> By: pathttp://www.kevinmd.com/blog/2009/08/is-reducing-medical-errors-similar-to-improving-transportation-safety.html#comment-109682 pat Tue, 18 Aug 2009 15:35:42 +0000 http://www.kevinmd.com/blog/?p=39573#comment-109682 It's possible to eventually get to the point where no one dies in an airplane crash, but it is not possible to get to the point where no one dies of anything. Since analyzing every death, complication, or health event will inevitably lead to some retrospective guessing that things might have gone differently, the definition of error itself in medicine is seen through many beholders. There is a growing public perception that all health badness can be "prevented" or "caught in time", and this is so far from the case that it defies our imagination as providers. The true problem with focusing on error is that it makes every bad outcome look like an error in the eyes of relatives and loved ones. It’s possible to eventually get to the point where no one dies in an airplane crash, but it is not possible to get to the point where no one dies of anything. Since analyzing every death, complication, or health event will inevitably lead to some retrospective guessing that things might have gone differently, the definition of error itself in medicine is seen through many beholders. There is a growing public perception that all health badness can be “prevented” or “caught in time”, and this is so far from the case that it defies our imagination as providers. The true problem with focusing on error is that it makes every bad outcome look like an error in the eyes of relatives and loved ones.

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