In Search of a Common Definition of Dx Error

Phillip Benton, MD, JD pgbentonmd at AOL.COM
Mon May 9 14:38:28 UTC 2016


 A 3rd ' foundational barrier', as we have heard all of our lives and of which juries are always reminded, is the fatalistic idea that "ACCIDENTS HAPPEN." Litigators call this the 'Forrest Gump defense'  - if you recall the scene in the movie where Forrest  steps into a pile of something very foul while jogging across the bridge, he looks at what is on his shoe and says calmly "that happens". 

This raises the problem of not just defining ERROR but also defining ACCIDENT, and then explaining how the two are distinguishable.

Phil Benton

-----Original Message-----
From: Elias Peter <pheski69 at GMAIL.COM>
Sent: Mon, May 9, 2016 12:28 am
Subject: Re: [IMPROVEDX] In Search of a Common Definition of Dx Error

I believe there are two foundational barriers to effective work on safety:

The mindset that sees errors as an issue related to the actions of individuals.
The focus of institutions on institutional health and success rather than on patient outcomes.

We need to frame safety as something the entire team owns, reserve punishment for willful malfeasance, reward the entire team much more than individuals for success, and accept that we cannot work on fixing something that we are afraid to talk about.

My frame of reference local action in small organizations, like a primary care practice with 10 clinicians, various community volunteer groups, teaching in a residency setting. I have found this approach to be surprisingly possible and effective at this smaller scale. Getting from here to there on a large scale? I wish I had an answer, but sharing ideas and reinforcing commitment in groups like this makes sense to me, as does the benefit of each of us making as much local change as we can.

Peter Elias, MD 

On 2016.05.06, at 1:36 PM, Vic Nicholls <nichollsvi2 at GMAIL.COM> wrote:

List members another something for you to consider when we talk about medical errors/mistakes/whatever.

I submit that it isn't just deaths we need to look at. In my case multiple records mistakes are made (for starters). Everyone gets into a huff & deny/defend when I ask to fix them. I've yet to sue any one, not threatening lawyers either. I'm saying fix this in a way that doctors who are doing my treatment forward can make the best decisions/judgement on my care. Work together as a team.

How are we going to help other doctors when they have to wade through screens/pages of stuff that isn't true or they don't know what is and what isn't? Either they get wrong assumptions or have to start from scratch.

WHY are doctors doing this to each other (much less patients)? Why hurt your own?? Surgeons eat their own and look where it got them.  :)

Seriously, the attitude of deny/defend and hide only makes things worse. Why? Because the mistakes are pretty obvious and the attitude towards fixing them, to listening to the patient, only gives the medical profession a worse black in the eye. If you think, like I do, admin are stiffing you in the back in many ways, this is another way they help to fuel major distrust in doctors AND the system. That means doctors who are in this list (and others I know) who are trying to figure out how/what/when/why for errors. When I say the system, it is doctors who are the face of it.

And yes, I've told admin to get front and center for their mistakes, and they copped out. Every time. Don't think we don't know some of your pain.

Consider that we could have the health care profession and patients working together, who would be a more efficient, cost cutting, and you'd get the better reputation for dealing with the problems, without all that (overbloating, $$$$ wasting IMO) admin.


On 5/6/2016 10:55 AM, Leonard Berlin wrote:

Over the past several days I have enjoyed reading the long list of commentaries submitted by very bright and caring physicians.  medical-associated people,  and researchers,  on the subject of the frequency of medical errors and their  role in causing death of patients. This has led me to conclude the following undeniable */_fact:_/*

The articles by Makary and others that calculate numbers related to medical errors and patient injury _are nothing more than statistical projections,  extrapolations, estimates, and conjectures. _

Makary, Johns Hopkins, and the BMJ got great international headlines by "estimating" that 251,454 patients die of medical mistakes annually. Needless to say, the word "estimating" doesn't appear very much,  if at all, in the headlines and limited text proclaimed  in newspaper and TV news reports.

Today, physicians  in all specialties are presumably  practicing   "evidence-based-medicine."

When it comes to medical errors, there is no "evidence!"

Yes, focusing attention on medical errors is certainly productive, and indeed encourages all of us to improve medical care safety and reduce errors.  And clearly, supporting organizations such as  SIDM is a step in the right direction.

We should be transparent to the public, but frightening everyone and causing them to lose confidence in their physicians is counterproductive. Our message to the public should be an honest one:  MEDICAL ERRORS DO OCCUR, BUT WE DO NOT KNOW, AND WILL NEVER KNOW, HOW MANY PATIENTS DIE DUE TO A MEDICAL ERROR; HOWEVER, WE ARE WORKING ON WAYS TO REDUCE THEM.

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