A culture of cover-up has slowed the patient safety movement

Promoting patient safety, preventing medical error, preventing physician error, preventing errors in diagnosis, preventing nurse error, preventing surgical error, preventing communication error, preventing health illiteracy error, preventing errors from language barriers, preventing laboratory error, preventing computer error, preventing patient mix-ups, preventing right and left side of body mix-ups, preventing mistakes, since mistakes are the stepping stones to failure.

Recognizing human frailty, recognizing physician humanity, recognizing system fallibility, owning up to problems, eliminating cover-up, acting out professionalism, recognizing that professionalism means self governance, individually and as groups.

Self criticism, peer criticism, a culture of peer review, honesty, truth, disclosure, fairness, and negotiated settlements.

Objective evaluation and commitment to quality. Quality improvement by preventing error. Systematic error, systematic prevention of error. An error caught before an action is taken based upon that error is, in effect, not an error.

These are the fundamental truths that the patient safety movement is all about.

A system is a regularly interacting or interdependent group of items forming a unified whole, a group of interactive bodies under the influence of related forces. Every organized effort is a subsystem within a set of interactive systems. Systems must include purpose, direction, plans, goals, and feedback loops. In theory, every loop should be closed.

Since the patient safety movement burst upon the scene some 20 years ago, the literature representing the body of work about patient safety has burgeoned. Academic knowledge has ballooned.

However, sad to say, improvement in documented actual patient safety has lagged grotesquely. Part of that retardation can be blamed upon a continuing culture of cover-up.

Since it is the safety of patients and not the management of risks for the medical system and its players that this is all about, I am heartened by the recently reported proposal that a regular system be established to encourage patients to report adverse events, said to affect 25% of all hospitalized patients .

This is one more process piece that could help begin to turn this large, recalcitrant, omnipresent problem around.

George Lundberg is a MedPage Today Editor-at-Large and former editor of the Journal of the American Medical Association.

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  • http://twitter.com/caroline815 Caroline Leopold

    I appreciate your perspective and will be curious how this AHRQ initiative goes. I am curious if patients will be allowed to report problems with accessing care because of insurance/finances. Do you have a citation for the statistic you cited that an estimated 25% of patients have adverse events in hospitals? I tried to track down the source of the figure and couldn’t find it. Thanks.

    • karen3

      The 25% statistic is from an HHS OIG report. they are good at writing stirring letters in favor of more money because of a serious problem, but give patients raspberries too.

  • JonSanders

    I spent forty years in industry before I retired. Industrial accidents kill 4300 people per year. My people are still working on making workplaces safer. Your people kill 100,000 people through accidents each year.

    Over the last two years I have learned that I must be my own patient advocate, a first responder in patient safety. I have learned to trust my industrial safety experience and not to defer to medical professionals just because they are medical professionals. There were times I said no and I was right. There were times when saying no would have been right. There was a time when I said no to a situation that would, in my workplace world, have gotten both of us fired, her for asking and me for going along with it.

    I have learned that medical records have two roughly equal functions, recording patient data and CYA.

    I have learned that when a hospital asks for feedback, they don’t really mean it. I’m keeping copies anyway.

    • karen3

      I think this is apt. I would also say that one should never believe a medical person to think of you as anything more than a billable carcass. It will make alot of things make more sense.

  • karen3

    There already exists such a system. In fact, there are many. QIO’s, the Joint Commission, State Inspectors, HHS OIG and a long number of other alphabet soups. We don’t need more, we need them to work. What they all have in common is a stalwart refusal to even read, much less address patient concerns. My mother was intentionally starved for a week, with no advanced directive, no permission. She received a black eye, She was left untreated with undisclosed cancer and state inspectors had no problem with that. In fact, the Joint Commission sent our complaint back in less than five hours. With an admission from Dr. Starvation that he had starved Mom because she was a paraplegic. Oh, and the fact that she was sent away from the ER twice after a CT showing a spinal cord injury, being left without treatment once at the hospital, illegal restraints, drugs with no current order, etc. God help you if you are a patient, because doctors literally have a license to commit intentional murder. I honestly believe that nothing will start to happen until doctors start going to jail.

    If you are really on the side of patients, I would recommend the Propublica facebook site. But we don’t hear from the medical profession often. The doctors would rather be in an echo chamber than to listen.

  • LBENT

    The problem is not just cover up, but punishment for those who try to uncover the truth. They become targeted physicians.

    • karen3

      Try being a patient who raises their head…

  • Rob Burnside

    I’d like to share an odd story about a medical mistake that probably saved my life. Several years ago, I was diagnosed with prostate cancer and sent for a bone scan. The radiologist misread this, and his report indicated metastasis in the spine. I was then sent for a CT scan, which ruled out PC metastasis and revealed an asymptomatic iliac aneurysm large enough to require prompt surgical intervention. Please feel free to draw your own conclusions. This is mine: a great many honest, instructive, and potentially life-saving mistakes may be the result of simple “human error” and until this can be safely admitted without fear of reproach or reprisal, progress in patient safety will be unnecessarily and undesirably slow.