I have mentioned the problem with criminalizing medical error previously. But I think some people are able to describe the issue much better than I can. I missed this when it first came out, but it remains relevant. Take a look here.
Author: RRHemphill
I am an emergency medicine physician by training, but have spent much of my career with a focus on trying to improve patient safety and quality of patient care. I have worked in government, military and large academic systems.
Checklists in Health Care
Introduction to checklists in health care
What is the Difference between Quality and Safety
The Institute of Medicine gave us a definition of Quality as noted below. In some ways this is a helpful way to think about what quality health care should mean, particularly from the perspective of a patient. Who would not want their care to be all of these things? And why would health systems not…
Listening
When trying to be a leader in patient safety (or in many other areas for that matter…), it helps to be a good listener. Yet, it’s not enough just to sit and listen like a lump on a log, you need to be an active and engaged listener. Check out this link to get a…
Medical Error and Misdiagnosis
Previously I linked to an article that discussed rates of misdiagnosis. The article noted how high the rates are and that they occur in a variety of settings – emergency departments, outpatient settings such as your doctor’s office, and inpatient settings. This most recent article looks at the emergency department and noted that there are…
Recent Article on Misdiagnosis
CNN just published an article on medial misdiagnosis. One might ask whether misdiagnosis is the same thing as a medical error. Read the article and we can give this more consideration later.
Why We Like To Place Blame
When we see mistakes made by other people, particularly those that case damage, harm, or loss we have a choice. We can understand that in many cases, particularly in a health care system, the individual was probably trying hard to achieve a good outcome. Or, we can blame them for the undesirable outcome. All too…
How Things Change (or don’t)
Without divulging too much information that might identify individuals, I wanted to share an event that happened recently. We had a provider who was feeling ill and went to a nurse and asked for a medication. The nurse wanted to help, went to the Pyxis, did a quick override, and then gave the medication. Nothing…
When Teams Don’t Communicate
This is the story of United Flight #173, Portland, Oregon. It is a bit of an old story, but still important This flight was preparing to land after an uneventful flight. But as they neared the airport the landing gear indicator light malfunctions. This means that the crew is not certain whether the landing gear is truly…
Why is Change So Hard?
I was recently thinking about how much time has passed since the report on “To Err is Human”. I think it is fair to say that some things are certainly better. Awareness of error is better. Reporting is better. Some types of errors have improved – for example hand writing errors are much better now…
Let’s Talk About Process Versus Outcome
When we think about an adverse event and error or an accident as witnesses, we get to see the outcomes of a long stream of actions and processes. People try to navigate their daily work in a manner that is meant to be both effective and efficient. They see problems and impediments to their daily…
Let’s Keep Talking About Culture
When trying to have a safe health care system, culture matters. A lot. The idea of a culture can be boiled down to “it’s the way we do things around here. We can train people all we want, but much of the way a new employee will behave, regardless of training, depends upon the culture. …
Putting a Just Culture into Action
When an accident or an error occurs, it can be very difficult not to respond in a punitive manner. But it is important to remember, that you are seeing the event at the conclusion. You now know the outcome of each decision made to that point in time and it is all too easy to…
Let’s Keep Looking at Safety – Why is this so hard?
If you are ever happened to be in Washington DC a few years ago and you were going to ride the Metro, you may have had the opportunity to use (or watch other try to use) the machines that would give you your Metro card (they use different machines now). It was really interesting to…
Creating A Culture of Safety
When we think about how people deal with the daily work in their systems, we need to understand that they are trying to make sense of complicated systems, but also trying to get things done. There are many things in our systems that make it hard to balance efficiency with safety. The absolute rules they…