Please register to participate in our discussions with 2 million other members - it's free and quick! Some forums can only be seen by registered members. After you create your account, you'll be able to customize options and access all our 15,000 new posts/day with fewer ads.
You remain pointless as most people aren't getting the point that you are trying to make. Arguing about the numbers seems like that is the most important point that you are trying to make. You also seem to concentrate on deadly errors there than simply all errors in general in order to sensationalize it.
I'm not sensationalizing it, it is sensational.
I try to pay attention to what bothers people, and it seems there are at least two people who are bothered by the numbers. If you like, I could broaden the subject to also include those who were harmed. Here's a link:
Medical Mistakes harm more than 1 in 10 patients. Many are preventable.
Quote:
There was a concerted effort put in place by national and state regulators such as JCAH mandates to reduce errors. The National Patient Safety Goals were initiated on a national level.
One thing noted and problematic from the very beginning is that if you punish people for making mistakes whether it is a small mistake or a large mistake is that there is no benefit for that person to report any mistake if they are going to get into trouble. That encourages hiding or ignoring mistakes.
"Part of the solution is to maintain a culture that works toward recognizing safety challenges and implementing viable solutions rather than harboring a culture of blame, shame, and punishment. Healthcare organizations need to establish a culture of safety that focuses on system improvement by viewing medical errors as challenges that must be overcome. All individuals on the healthcare team must play a role in making the provision of healthcare safer for patients and healthcare workers."
So it went from the blame game to encouraging reporting of errors in order to change the system that caused them to happen. That way people wouldn't be hiding errors.
Early on in implementing error reduction, there was a harsh system put in place that penalized people for making mistakes, and at my place of work they came up with a point system where if you made three major errors then you would get fired. The problem was is that they got to determine what constituted a major error vs a minor error. Not noticing a misspelled name or if the hospital number was an L instead of a 1 constituted a major error in labeling blood specimens. Three of those and you get fired. It didn't matter that the error didn't transfer to clinical outcomes. It didn't matter if nothing happened to the patient. So if somebody missed it then the next person would ignore it in order not to get the other person in trouble if they had already made too many added up point system errors. I had a nurse time of whom I informed from the ER about the mistake on labeling actually going all the way up into the lab and asked me to please not report it because she had already made labeling errors before and wanted to kiss me in order to throw that in as a bonus. She got crouched near me while I was working in a biohood. I said thanks but just re-label the specimen appropriately and we will forget it. She was very happy.
That changed to less of a blame game and they got rid of the point system to emphasize the process if an issue could be tied to a process. Major errors resulting in patient care impact are still addressed on a per-incident basis and can include termination of employment. I have seen that happen. They reported a negative pregnancy test instead of a positive result.
Most people out in the community don't like that emphasis on reducing blame. They want to go after anybody who makes a mistake and they should all be punished as the point system did. In reality, if you want true change and error reduction then you need to address the system and process that caused the error if any.
Most people who want to be vindictive rather than problem-solving usually have other motives for pushing another agenda.
I don't know what to say about all of that because I don't know all the facts. It might be the threat of law suits that worries those in charge.
There are so many different situations in the medical field that we could talk about this forever.
There are problems with laboratory pathologists not being accurate in determining whether biopsy cells are cancerous or not.
There are doctors who make diagnostic errors.
There are doctors who, for one reason or another, don't like to give their patients bad news about their health condition, so they don't. It happened with my HMO doctor and was covered up. I found out about it in a round-about way. Everyone at the clinic was told that he was transferred to a desk job. But someone with access to inside information told me he was withholding bad test results. So it's likely he was fired.
So why did the HMO cover for him? Most likely they were fearful of potential law suits.
And, as I mentioned earlier, it's common for doctors to prescribe multiple drugs to their elderly patients, not knowing what the effects will be because all medications are tested and approved individually - not in various combinations. I personally met one elderly man at an HMO seminar who said he was taking 10 drugs. That's not treatment based on science, that's testing things out on the patient.
The problem with that is there are no repercussions because an elderly person's life is considered to not be worth much. I know because my mother was harmed by a wrong diagnosis and when I called various lawyers they all said they would not take the case because there wouldn't be enough money in it to make it worth the effort. And the same will apply to prescribing multiple drugs. Most of the time elderly patients don't recognize the danger of doing this, they believe their doctor wouldn't do it if it was dangerous. But doctors do it all the time.
Doctors prescribe multiple drugs, but pharmacists are the ones who are responsible for reviewing the medication list and ensuring that there are no adverse interactions or overdose. If the patient doesn’t tell the pharmacist all the medications he/she is taking, then there may be problems with drug interactions. This is not uncommon as a person may go to pharmacy A for most medications, but because two medications are compounded, she has to go to pharmacy B for those, and she goes to pharmacy C for another medication because the price there is much cheaper than it is at pharmacy A. Additionally, the person gets these medications from her primary care doctor and 3 other specialists, none of whom know the full medication list.
There is a huge chance of error here. A lot of people complain about sharing records with other providers, but this is why. It may be that medication A is causing side effects that might be the reason to go to a specialist, but if the patient doesn’t mention that medication, then the option may be to prescribe yet another medication that results in side effects causing the person to go to another specialist. The lists go on. Doctors are human and pharmacists only have access to the information they are given by relevant providers. If no one has all the information, mistakes can and do occur.
I try to pay attention to what bothers people, and it seems there are at least two people who are bothered by the numbers. If you like, I could broaden the subject to also include those who were harmed. Here's a link:
Medical Mistakes harm more than 1 in 10 patients. Many are preventable.
I don't know what to say about all of that because I don't know all the facts. It might be the threat of law suits that worries those in charge.
There are so many different situations in the medical field that we could talk about this forever.
There are problems with laboratory pathologists not being accurate in determining whether biopsy cells are cancerous or not.
There are doctors who make diagnostic errors.
There are doctors who, for one reason or another, don't like to give their patients bad news about their health condition, so they don't. It happened with my HMO doctor and was covered up. I found out about it in a round-about way. Everyone at the clinic was told that he was transferred to a desk job. But someone with access to inside information told me he was withholding bad test results. So it's likely he was fired.
So why did the HMO cover for him? Most likely they were fearful of potential law suits.
And, as I mentioned earlier, it's common for doctors to prescribe multiple drugs to their elderly patients, not knowing what the effects will be because all medications are tested and approved individually - not in various combinations. I personally met one elderly man at an HMO seminar who said he was taking 10 drugs. That's not treatment based on science, that's testing things out on the patient.
The problem with that is there are no repercussions because an elderly person's life is considered to not be worth much. I know because my mother was harmed by a wrong diagnosis and when I called various lawyers they all said they would not take the case because there wouldn't be enough money in it to make it worth the effort. And the same will apply to prescribing multiple drugs. Most of the time elderly patients don't recognize the danger of doing this, they believe their doctor wouldn't do it if it was dangerous.
A mistake is a mistake and there is very little one can say about such examples of mistakes. One needs to address the things can one can do to avoid such mistakes and that is being done.
On a higher level though is the strategy in order to accomplish what you want to accomplish and you mention that no one is being punished or there are no repercussions. There has to be a balancing act between being too repressive that would result in hiding errors and not being open about them.
Here is one concern and one example.
"Will Prosecuting Medical Errors Lead to a Culture of Silence?
— Healthcare workers fearful of repercussions from former nurse RaDonda Vaught's conviction
by Kristina Fiore, Director of Enterprise & Investigative Reporting, MedPage Today March 28, 2022
Healthcare workers are alarmed by the conviction of former Nashville nurse RaDonda Vaught, who now faces prison time over a medical error.
"We could all and probably have been close to this situation because we're continuously stretched too thin," Kelsey Fassold, RN, an ICU nurse, said in a LinkedIn post. "We try so hard to do the best by our patients while the odds are stacked against us."
Jeremy Faust, MD, MedPage Today's editor-in-chief, said in an Inside Medicine post that the verdict "may contribute to a culture of silence around medical errors."
"Such silence may make systemic problems less readily identified and rectified. This is the opposite of what we need," Faust wrote. "We need to destigmatize human errors, acknowledge them, and learn from them."
On Friday, Vaught was convicted of negligent homicide and gross neglect of an impaired adult, after she allegedly gave 75-year-old Charlene Murphey the paralytic vecuronium when she was meant to give her the anti-anxiety drug Versed. Vaught had been acquitted of a reckless homicide charge.
Vaught faces 1 to 2 years in prison for the negligent homicide charge, and 3 to 6 years on the gross neglect charge, according to Kaiser Health News. Her sentencing is scheduled for May 13.
Typically, serious medical errors are handled by licensing boards or civil courts -- not prosecutors."
It's not as simple as just punishing individuals. Most errors are process systemic errors and so blaming the individual and not looking at the process is not helpful. You can fire the person but you have not changed the process that caused the error in the first place. It's simply about punishment and repercussions. That's scapegoating and looking for a person to blame everything on.
It's impossible to predict every drug combination out there no pharmaceutical company is going to do studies with all the various combinations of drugs out there. I am not a pharmacist and I would ask them for input and they do have computer programs that look out for drug interactions based on broad modes of actions of drugs. Some drugs are compounded already that way such as blood pressure medicine containing two active drugs on one pill like Lisinopril-HCTZ. You want more safety studies then it will cost you and if you want more safety then it will cost you for computer programs and using barcodes and lots more of added costly technology inclusive of adding more staff not to be overworked.
As to missed cancers, most are missed by clinicians not checking or simply attributing symptoms to something else. The odds are much higher there to be missed or dismissed compared to pathologist misdiagnosis which happen but at much less incidence. If any pathologist is unsure they have a staff review with 5 or 6 pathologists all getting together and looking at the slide together and coming to a consensus. That's what they do with difficult cases and they also have tumor boards that review cancer cases.
Doctors prescribe multiple drugs, but pharmacists are the ones who are responsible for reviewing the medication list and ensuring that there are no adverse interactions or overdose. If the patient doesn’t tell the pharmacist all the medications he/she is taking, then there may be problems with drug interactions. This is not uncommon as a person may go to pharmacy A for most medications, but because two medications are compounded, she has to go to pharmacy B for those, and she goes to pharmacy C for another medication because the price there is much cheaper than it is at pharmacy A. Additionally, the person gets these medications from her primary care doctor and 3 other specialists, none of whom know the full medication list.
There is a huge chance of error here. A lot of people complain about sharing records with other providers, but this is why. It may be that medication A is causing side effects that might be the reason to go to a specialist, but if the patient doesn’t mention that medication, then the option may be to prescribe yet another medication that results in side effects causing the person to go to another specialist. The lists go on. Doctors are human and pharmacists only have access to the information they are given by relevant providers. If no one has all the information, mistakes can and do occur.
One would need a national database in order to share information and that costs money. That was one of President Obama's visions but fought against by people worried about privacy rights. Then we have HIPAA which says you can't share information without the person's approval so they have an out of any system.
There is a reason why countries with a national healthcare system have faster and more easily obtainable national data banks and they make good use of them.
We basically follow Israel with their quick studies as to what is happening with the virus. It is very difficult for us to replicate that with our disjointed system.
I am not interested in superficial hit-and-run headline topics with no meat-to-the-bone discussions meant solely for shock and awe. That pattern is beginning to build and it won't be well received by many.
12000 deaths/year from unnecessary surgery
7000 deaths/year from medication errors in hospitals
20000 deaths/year from other errors in hospitals
80000 deaths/year from nosocomial infections in hospitals
106000 deaths/year from nonerror, adverse effects of medications
These total to 225000 deaths per year from iatrogenic causes.
One makes lemonade out of lemons. Why somebody brought the lemons one would have to ask them. It seems personal experience has shaped perceptions. I try to minimize my personal bias while others tend to globalize them.
The hospital that I worked with tended to view the actual practice of healthcare delivery as a service industry much like the way hotels are run. People will come back and keep the hospital open. If they don't come back or don't like the hospital then it will close. We were trained on how to deal with unruly patients and make sure we address their concerns and not ignore them no matter how crazy they are (my words). If everything is win-win when things are done right.
I am new here and I am sure regulars know who the trolls are but I also worry sometimes that somebody new coming here will be put off by aggressive responses of people working in healthcare. If we get more callous then the perception out there of people will break that bond that has existed between healthcare workers and the community we live in.
There have been death threats to healthcare providers and in the case mentioned an RN was convicted of a criminal offense for medical error when in the past that was unheard of. We also have many professionals leaving the healthcare industry. It's very disappointing and saddening to see this happen in my lifetime. It not only impacts healthcare workers but also impacts patient care.
12000 deaths/year from unnecessary surgery
7000 deaths/year from medication errors in hospitals
20000 deaths/year from other errors in hospitals
80000 deaths/year from nosocomial infections in hospitals
106000 deaths/year from nonerror, adverse effects of medications
These total to 225000 deaths per year from iatrogenic causes.
that data is 24 years old or older as noted in the citations.
I don't know what to say about all of that because I don't know all the facts.
The best and most important post you made. For once, I totally agree with you.
Please register to post and access all features of our very popular forum. It is free and quick. Over $68,000 in prizes has already been given out to active posters on our forum. Additional giveaways are planned.
Detailed information about all U.S. cities, counties, and zip codes on our site: City-data.com.
Please register to participate in our discussions with 2 million other members - it's free and quick! Some forums can only be seen by registered members. After you create your account, you'll be able to customize options and access all our 15,000 new posts/day with fewer ads.
