Comments on: Is incident reporting effective in reducing medical errors and increasing patient safety? http://www.kevinmd.com/blog/2009/10/incident-reporting-effective-reducing-medical-errors-increasing-patient-safety.html Tue, 14 Feb 2012 23:57:00 +0000 hourly 1 By: Doc Stonehttp://www.kevinmd.com/blog/2009/10/incident-reporting-effective-reducing-medical-errors-increasing-patient-safety.html#comment-113509 Doc Stone Wed, 07 Oct 2009 23:19:37 +0000 http://www.kevinmd.com/blog/?p=40438#comment-113509 "That is true for the pilots and flight attendants, but not the air traffic controllers, mechanics, or security screeners."Which is why the pilot doesn't blindly trust air traffic control but watches out for himself anyway, does a preflight to check behind the mechanics, and together with the rest of the crew is less than 100% trusting of the passengers.I would have be dead today had I always followed air traffic control's instructions.Doctors, like pilots, must take ultimate responsibility for the entire process. It is depressing to hear physicians throw up their hands in the face of non-performance and patient harm and say "What can I do. It isn't my job to . . . (and cite some ancillary function which is there to assist him)." If the doctor doesn't take responsibility for the entire process, then who is responsible? No one. Then the patient doesn't get what they need, and yet nothing gets done about it.If you are a physician then you are responsible for the entire care process for your patient, from triage to aftercare planning. If someone else isn't doing their job, you need to either do it yourself, get them to do it, get someone else to do it, or move your patient to a more functional location. That is the duty. Notice that it doesn't include a "as long as it is convenient" or "as long as no one thinks I am not a team player" or "as long as my income doesn't go down." That is part of the problem with the vague lable "disruptive physician". If the process is dysfunctional to the point of compromising patient care, you have a duty to disrupt it. “That is true for the pilots and flight attendants, but not the air traffic controllers, mechanics, or security screeners.”

Which is why the pilot doesn’t blindly trust air traffic control but watches out for himself anyway, does a preflight to check behind the mechanics, and together with the rest of the crew is less than 100% trusting of the passengers.

I would have be dead today had I always followed air traffic control’s instructions.

Doctors, like pilots, must take ultimate responsibility for the entire process. It is depressing to hear physicians throw up their hands in the face of non-performance and patient harm and say “What can I do. It isn’t my job to . . . (and cite some ancillary function which is there to assist him).” If the doctor doesn’t take responsibility for the entire process, then who is responsible? No one. Then the patient doesn’t get what they need, and yet nothing gets done about it.

If you are a physician then you are responsible for the entire care process for your patient, from triage to aftercare planning. If someone else isn’t doing their job, you need to either do it yourself, get them to do it, get someone else to do it, or move your patient to a more functional location. That is the duty. Notice that it doesn’t include a “as long as it is convenient” or “as long as no one thinks I am not a team player” or “as long as my income doesn’t go down.” That is part of the problem with the vague lable “disruptive physician”. If the process is dysfunctional to the point of compromising patient care, you have a duty to disrupt it.

]]> By: Michael Kirsch, M.D.http://www.kevinmd.com/blog/2009/10/incident-reporting-effective-reducing-medical-errors-increasing-patient-safety.html#comment-113490 Michael Kirsch, M.D. Wed, 07 Oct 2009 16:56:23 +0000 http://www.kevinmd.com/blog/?p=40438#comment-113490 I'm skeptical of skepticus. I don't endorse a system of punishments and consequences. I think the prospects for success are greater if camaraderie is fostered and all players feel that are on a team pursuing a common goal. I'd rather that folks pursue a reward than fear a reprisal. I’m skeptical of skepticus. I don’t endorse a system of punishments and consequences. I think the prospects for success are greater if camaraderie is fostered and all players feel that are on a team pursuing a common goal. I’d rather that folks pursue a reward than fear a reprisal.

]]> By: skeptikushttp://www.kevinmd.com/blog/2009/10/incident-reporting-effective-reducing-medical-errors-increasing-patient-safety.html#comment-113487 skeptikus Wed, 07 Oct 2009 15:10:28 +0000 http://www.kevinmd.com/blog/?p=40438#comment-113487 Doc Stone is right. Doctors, like pilots, must have "more skin" in the safety game. The only way to do that is PUNISHMENT. Doctors who forget to wash their hands, should have to pay fines. Patients should be able to collect those fines.Believe me you'd see more docs washing their hands and more patients being vigilent in protecting themselves against hospital bred bugs. Doc Stone is right. Doctors, like pilots, must have “more skin” in the safety game. The only way to do that is PUNISHMENT. Doctors who forget to wash their hands, should have to pay fines. Patients should be able to collect those fines.

Believe me you’d see more docs washing their hands and more patients being vigilent in protecting themselves against hospital bred bugs.

]]> By: MillCreekhttp://www.kevinmd.com/blog/2009/10/incident-reporting-effective-reducing-medical-errors-increasing-patient-safety.html#comment-113485 MillCreek Wed, 07 Oct 2009 14:50:20 +0000 http://www.kevinmd.com/blog/?p=40438#comment-113485 I would agree that the yield of the typical incident reporting system can be low, in terms of actionable items that have a relevant impact on patient safety. I do not believe that every IR needs to have a root cause analysis or the like.In some systems, IR counts and the trends thereto have become more important than analysis and action upon the content of the report. I would agree that the yield of the typical incident reporting system can be low, in terms of actionable items that have a relevant impact on patient safety. I do not believe that every IR needs to have a root cause analysis or the like.

In some systems, IR counts and the trends thereto have become more important than analysis and action upon the content of the report.

]]> By: Michael Kirsch, M.D.http://www.kevinmd.com/blog/2009/10/incident-reporting-effective-reducing-medical-errors-increasing-patient-safety.html#comment-113477 Michael Kirsch, M.D. Wed, 07 Oct 2009 13:10:11 +0000 http://www.kevinmd.com/blog/?p=40438#comment-113477 Incident reports are a relic that needs to be reformed or retired. As pointed out in the post, the # IRs files is far less than those that could be filed. We don't know what the denominator is. The nursing profession regards these as a punitive report, not an opportunity for self-improvement. When I have had an issue with a nurse, I handle it personally without an IR or similar document. I think this approach has worked well. Incident reports are a relic that needs to be reformed or retired. As pointed out in the post, the # IRs files is far less than those that could be filed. We don’t know what the denominator is. The nursing profession regards these as a punitive report, not an opportunity for self-improvement. When I have had an issue with a nurse, I handle it personally without an IR or similar document. I think this approach has worked well.

]]> By: Anonymoushttp://www.kevinmd.com/blog/2009/10/incident-reporting-effective-reducing-medical-errors-increasing-patient-safety.html#comment-113471 Anonymous Wed, 07 Oct 2009 04:45:14 +0000 http://www.kevinmd.com/blog/?p=40438#comment-113471 <blockquote>A critical difference between aviation and medicine is that in the former, the professionals own lives are at stake. It does wonders to focus the attention and counter the excuse making, finger pointing, and denial. For the pilot, it doesn’t matter whose is at fault in the error, he is always 100% invested in preventing it.</blockquote>That is true for the pilots and flight attendants, but not the air traffic controllers, mechanics, or security screeners.

A critical difference between aviation and medicine is that in the former, the professionals own lives are at stake. It does wonders to focus the attention and counter the excuse making, finger pointing, and denial. For the pilot, it doesn’t matter whose is at fault in the error, he is always 100% invested in preventing it.

That is true for the pilots and flight attendants, but not the air traffic controllers, mechanics, or security screeners.

]]> By: Is incident reporting effective in reducing medical errors and increasing patient safety? « The ACUTE CARE Blog: Non-Urban Emergency Medicinehttp://www.kevinmd.com/blog/2009/10/incident-reporting-effective-reducing-medical-errors-increasing-patient-safety.html#comment-113467 Is incident reporting effective in reducing medical errors and increasing patient safety? « The ACUTE CARE Blog: Non-Urban Emergency Medicine Wed, 07 Oct 2009 00:12:06 +0000 http://www.kevinmd.com/blog/?p=40438#comment-113467 [...] Is incident reporting effective in reducing medical errors and increasing patient safety? Posted on October 7, 2009 by coptermedic A (contrarian) guest post from Dr. Bob Wachter on KevinMD: [...] [...] Is incident reporting effective in reducing medical errors and increasing patient safety? Posted on October 7, 2009 by coptermedic A (contrarian) guest post from Dr. Bob Wachter on KevinMD: [...]

]]> By: Doc Stonehttp://www.kevinmd.com/blog/2009/10/incident-reporting-effective-reducing-medical-errors-increasing-patient-safety.html#comment-113463 Doc Stone Tue, 06 Oct 2009 22:58:07 +0000 http://www.kevinmd.com/blog/?p=40438#comment-113463 A critical difference between aviation and medicine is that in the former, the professionals own lives are at stake. It does wonders to focus the attention and counter the excuse making, finger pointing, and denial. For the pilot, it doesn't matter whose is at fault in the error, he is always 100% invested in preventing it. A critical difference between aviation and medicine is that in the former, the professionals own lives are at stake. It does wonders to focus the attention and counter the excuse making, finger pointing, and denial. For the pilot, it doesn’t matter whose is at fault in the error, he is always 100% invested in preventing it.

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