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http://scienceblogs.com/insolence/2010/01/unforgivable_medical_errors.php#more"...
In my field of surgery, there are some unforgivable errors. Although some of us may disagree on the exact identity of some of them, most surgeons would agree on a handful of them. Certainly one of them would be to amputate the wrong limb or remove the wrong organ. This happens far more often than any of us would like to admit. Over the last couple of decades, checklists meant to prevent such occurrences have risen to the fore and become standard practice at most hopsitals. We surgeons ridicule them (myself included, at least until recently), but they work, as an increasing amount of scientific and clinical literature is showing. Another unforgivable error is to leave a sponge or surgical instrument behind during an uncomplicated elective case. I qualify that because it's understandable that occasionally a sponge will be left behind in a trauma case or when an elective case goes bad. In both cases, things get crazy, and everyone is frantically trying to save the patient. But in the elective case, leaving a sponge or surgical instrument behind should in essence never happen. The tedious ritual of counting the sponges, needles, and instruments before and after the case is highly effective in preventing it--when surgeons listen to the nurse telling them that the counts aren't correct. The third unforgivable error is to operate on the wrong patient, which has occasionally happened in the past. Again, checklists make such a spectacular mistake much less likely. At my own hospital, for instance, the nurses are required to ask each patient who he or she is, what operation she is having, who the surgeon is, and, if it's appropriate for the operation, which side is being operated on. The surgeon is required to mark the body part and the side with his or her initials. Sure it sounds silly and pointless, but it's clear that such systems reduce wrong site surgery markedly.
It's becoming increasingly clear that most medical errors of these types are in actuality system problems. As much as surgeons like to think of themselves as incapable of making such errors, the fact is that we all are. The key to reducing such errors is to make the system such that it is more difficult to make such mistakes or, when mistakes are made, they are highly likely to be caught before a patient is injured. There are other areas of medicine where this is also true. One in particular came to national prominence in a story published in the New York Times over the weekend entitled The Radiation Boom: Radiation Offers New Cures, and Ways to Do Harm. It is a hugely disturbing story of errors in radiation therapy that caused significant harm to many patients, including deaths.
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Reducing medical errors that harm patients is about more than just physicians. It's about the whole system. In surgery we have been discovering this (and struggling with it) over the last decade or so. It's not enough just to target the physicians. In my specialty and in the operating room, it's necessary that everyone be involved, from the nurse who sees the patient when he comes in, the physicians who do the surgery, the scrub techs counting instruments, the scrub nurse verifying surgical site--in essence everyone involved with the care of the patient from the moment he shows up for surgery to the moment he either goes home or is admitted to the hospital. Radiation oncology has at least as many people involved in the care of the patient, if not more: Nurses, radiation physicists, radiation oncologists, technicians operating the machinery. Moreover, because unlike surgery radiation is often given in small fractions over many visits, there are many more opportunities for error than in surgery. After all, you have surgery once; typical radiation therapy regimens for breast cancer involve 33 doses of radiation, each with the potential for errors both small and large. It only took three such errors to kill Jerome-Parks and one error at the beginning and not caught to kill Jn-Charles.
We had a hard time learning this lesson in surgery. In fact, we're still having a lot of trouble learning it, and there is still a lot of resistance. It is human nature. However, as systems become more complicated, the potential for not just human error but errors that derive from interactions within the system itself even when each person involved makes no mistakes. While we as health care practitioners should always strive to do our best and make as few mistakes as possible, mistakes do happen. They are inevitable. We have to be more like the airline industry and build systems that are designed to catch these errors before they can harm patients and minimize the harm done. We have a long way to go, unfortunately."------------------------------------------- There's much more to the piece at the link, and, of course, one piece does not cover the issue. This piece does touch on the complexities of health care, and the systems of health care, which need to be addressed big time.
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