Ootrazh du Jour

[Orestes Munn]

Why do we tolerate this?

http://www.npr.org/sections/health-shots/2016/05/03/476636183/death-certificates-undercount-toll-of-medical-errors

Email me if you want the full text of the paper. I think it's paywalled.

[LarryHoward]

Why do we tolerate this?

http://www.npr.org/sections/health-shots/2016/05/03/476636183/death-certificates-undercount-toll-of-medical-errors

Email me if you want the full text of the paper. I think it's paywalled.

Perhaps an expected result of medical malpractice lawsuits? I can see the plaintiff's lawyer waving a death certificate and telling the jury "if not for this horrible mistake, this loving father would be able to dance with his daughter at her wedding."

How much medical error is actionable and how much is a result of an M&M review that uncovers missed diagnostic signs and human errors?

[Rob McAlpine]

E, I'd like a copy of the paper, although as an engineer I'm probably to stupid to understand.

One of the questions I'd have relates to someone dying today due to an error, when they would have died in 30 days regardless because they were really sick and not going to get better. Do some of these errors hasten death as opposed to causing it? People who are really ill can be sent off by a relatively minor error, I suspect. What really worries me is the thought of an otherwise healthy person heading to Fiddler's Green due to medical errors.

The front page of the Midland paper this morning declared that "1 in 3 Midland residents has some level of mental health need". Really? Is 1/3 of the whole world in need of treatment?

http://www.mrt.com/health_and_wellness/ ... 7c6fd.html

[Orestes Munn]

E, I'd like a copy of the paper, although as an engineer I'm probably to stupid to understand.

One of the questions I'd have relates to someone dying today due to an error, when they would have died in 30 days regardless because they were really sick and not going to get better. Do some of these errors hasten death as opposed to causing it? People who are really ill can be sent off by a relatively minor error, I suspect. What really worries me is the thought of an otherwise healthy person heading to Fiddler's Green due to medical errors.

The front page of the Midland paper this morning declared that "1 in 3 Midland residents has some level of mental health need". Really? Is 1/3 of the whole world in need of treatment?

http://www.mrt.com/health_and_wellness/ ... 7c6fd.html

Yes, I thought of that, too. This really needs to be expressed in lost days of life or quality-of-life/time to be really useful.

The article is not very technical.

Want more bad news about US Medicine? 1 in 3 antibiotic prescriptions is probably unnecessary. https://www.washingtonpost.com/news/to-your-health/wp/2016/05/03/1-in-3-antibiotics-prescribed-in-u-s-are-unnecessary-major-study-finds/

I suppose mental health needs are kind of subjective at the margins, at least, but I'd like to know what they mean.

[BeauV]

I have only one word for my experience with this: SPIKE

Sadly, what killed Spike was probably an error, probably avoidable, but it will probably happen again and again. As I understand it, the doc on duty made a judgement call and was wrong.

I've had a lot of long talks about bad judgement calls with my son John, the Marine. Arguably, like doctors, Marie Corps officers have an immediate and direct effect on the life span of the folks in their command. They have a system of review, much like an M&M meeting. Much like what I've personally seen in medicine there is a certainly level of ass-covering and protecting of their own folks. But quite literally every day during John's training some Sargent or Officer would say: "You're learning this and you're going to do it right so you don't get some of My Marines killed." they almost always say it the same way. It instills a really serious level of peer pressure to protect each other and care for each other. While I think that my medical friends often exhibit a genuine "I'll do anything to save this person" attitude, the volume of patients, the complexity, and the difficulty of getting it all right makes this even tougher than it is for the Marine.

What I am absolutely unwilling to accept, and I've personally seen, is that Doctors who are clearly not competent are left in the job. That, more than any error made in good faith, is unconscionable. But only their peers can remove them. The CDC and what's on a death certificate can't do the job, but fixing that will help.

"You get what you measure. If you're not getting what you want, measure something else." (From my first and best boss.)

[Orestes Munn]

Bad judgement is the least of it, from what I read. The problems are procedural: incomplete or erroneous sign-outs (handoffs between nurses and docs), errors or failures of documentation, failure to read records, confusion over drug names and doses, wrong patient, etc.

If someone you love gets "involved with the system," watch like a hawk and question everything.

[Tucky]

I have no experience with risk management, but understand that commercial flying in the US is the gold standard in terms of low rate of accidents and injury (I read that it is generally lower than statistically possible). Airlines and pilots have legal protection limiting collection and damages and also have an error review system that works. I don't see anything to suggest that the connection between these two facts is not important. Medicine deserves the same.

[BeauV]

Bad judgement is the least of it, from what I read. The problems are procedural: incomplete or erroneous sign-outs (handoffs between nurses and docs), errors or failures of documentation, failure to read records, confusion over drug names and doses, wrong patient, etc.

If someone you love gets "involved with the system," watch like a hawk and question everything.

Eric, I've served as the "Guardian" of various folks in the "system". It is a critical role. My X-Wife, the mother of my Marine, served as Guardian when he went in for back surgery. The Navy doc in San Diego even called her back to ask if she'd consider doing that on a regular basis. Nothing like a Mama Bear who has a cub in surgery! Our entire family has this built in and I'd highly recommend it to anyone going into the System. The Guardian is someone with all the data, all the reports, all the test results, and has an attitude that basically says: "If you're going to do anything to my patient you have to come through me first." The doctors usually don't like it at all, so we always give the Guardian medical control and tell the doctors that. I STRONGLY recommend this and if you can get a medical person to be your guardian it's even better.

BTW, before John can order his battery of 155 cannons to fire it takes four closed loop confirmations. This is not because they don't trust John. It is because the Marines have shelled themselves far too many times by accident, violating the directive "Don't get some of my Marines killed." John reports that while he's never personally made an error that was caught by the system, he has already (in two years) seen two times when the system worked. I suppose it would be a bit like a doctor laying out the operation pre-op for another doc and then asking if they thought that made sense. Four times!

[Orestes Munn]

I have no experience with risk management, but understand that commercial flying in the US is the gold standard in terms of low rate of accidents and injury (I read that it is generally lower than statistically possible). Airlines and pilots have legal protection limiting collection and damages and also have an error review system that works. I don't see anything to suggest that the connection between these two facts is not important. Medicine deserves the same.

This is an important comparison and let us not forget that there is another profitable and influential industry selling insurance insurance and legal services to defendants and plaintiffs in medical negligence actions. Legal protections for physicians and institutions would cut into this. However, health care may also be intrinsically more dangerous than commercial aviation.

Another factor might be that the pilot dies along with his passengers, if (s)he screws up. I bet that fact, in and of itself, eliminates some error.

[Tim Ford]

Why do we tolerate this?

http://www.npr.org/sections/health-shots/2016/05/03/476636183/death-certificates-undercount-toll-of-medical-errors

I know!!! I have a hard time tolerating NPR, too!

[BeauV]

I have no experience with risk management, but understand that commercial flying in the US is the gold standard in terms of low rate of accidents and injury (I read that it is generally lower than statistically possible). Airlines and pilots have legal protection limiting collection and damages and also have an error review system that works. I don't see anything to suggest that the connection between these two facts is not important. Medicine deserves the same.

This is an important comparison and let us not forget that there is another profitable and influential industry selling insurance insurance and legal services to defendants and plaintiffs in medical negligence actions. Legal protections for physicians and institutions would cut into this. However, health care may also be intrinsically more dangerous than commercial aviation.

Another factor might be that the pilot dies along with his passengers, if (s)he screws up. I bet that fact, in and of itself, eliminates some error.

Precisely the reason that the 2nd Lt. calling in the artillery or air strike is the "final" person to say "yes" to the coordinates that the weapons are going to target. If he gets it wrong, he gets killed.

Don't ever underestimate the power of these entrenched industries. They have executed classic "regulatory capture" and proved just how powerfully they could defend themselves during Bill Clinton's presidency as they crushed a very good proposal for restructuring health-care made by Hillary's committee.

[Orestes Munn]

I have no experience with risk management, but understand that commercial flying in the US is the gold standard in terms of low rate of accidents and injury (I read that it is generally lower than statistically possible). Airlines and pilots have legal protection limiting collection and damages and also have an error review system that works. I don't see anything to suggest that the connection between these two facts is not important. Medicine deserves the same.

This is an important comparison and let us not forget that there is another profitable and influential industry selling insurance insurance and legal services to defendants and plaintiffs in medical negligence actions. Legal protections for physicians and institutions would cut into this. However, health care may also be intrinsically more dangerous than commercial aviation.

Another factor might be that the pilot dies along with his passengers, if (s)he screws up. I bet that fact, in and of itself, eliminates some error.

Precisely the reason that the 2nd Lt. calling in the artillery or air strike is the "final" person to say "yes" to the coordinates that the weapons are going to target. If he gets it wrong, he gets killed.

Don't ever underestimate the power of these entrenched industries. They have executed classic "regulatory capture" and proved just how powerfully they could defend themselves during Bill Clinton's presidency as they crushed a very good proposal for restructuring health-care made by Hillary's committee.

Yeah, and I have pocketed more than my share of their money, too. However, if we want them and the bad effects of gag orders on safety to go away, we need a non-adversarial alternative that compensates victims of error and negligence and mandates action when they happen.

[kimbottles]

I have only one word for my experience with this: SPIKE

Sadly, what killed Spike was probably an error, probably avoidable, but it will probably happen again and again. As I understand it, the doc on duty made a judgement call and was wrong.

I've had a lot of long talks about bad judgement calls with my son John, the Marine. Arguably, like doctors, Marie Corps officers have an immediate and direct effect on the life span of the folks in their command. They have a system of review, much like an M&M meeting. Much like what I've personally seen in medicine there is a certainly level of ass-covering and protecting of their own folks. But quite literally every day during John's training some Sargent or Officer would say: "You're learning this and you're going to do it right so you don't get some of My Marines killed." they almost always say it the same way. It instills a really serious level of peer pressure to protect each other and care for each other. While I think that my medical friends often exhibit a genuine "I'll do anything to save this person" attitude, the volume of patients, the complexity, and the difficulty of getting it all right makes this even tougher than it is for the Marine.

What I am absolutely unwilling to accept, and I've personally seen, is that Doctors who are clearly not competent are left in the job. That, more than any error made in good faith, is unconscionable. But only their peers can remove them. The CDC and what's on a death certificate can't do the job, but fixing that will help.

"You get what you measure. If you're not getting what you want, measure something else." (From my first and best boss.)

It was an absolute error that killed SPIKE. There is no reason he should have died. The Doctor Fucked up. Pure and simple.

[kimbottles]

Bad judgement is the least of it, from what I read. The problems are procedural: incomplete or erroneous sign-outs (handoffs between nurses and docs), errors or failures of documentation, failure to read records, confusion over drug names and doses, wrong patient, etc.

If someone you love gets "involved with the system," watch like a hawk and question everything.

Eric, I've served as the "Guardian" of various folks in the "system". It is a critical role. My X-Wife, the mother of my Marine, served as Guardian when he went in for back surgery. The Navy doc in San Diego even called her back to ask if she'd consider doing that on a regular basis. Nothing like a Mama Bear who has a cub in surgery! Our entire family has this built in and I'd highly recommend it to anyone going into the System. The Guardian is someone with all the data, all the reports, all the test results, and has an attitude that basically says: "If you're going to do anything to my patient you have to come through me first." The doctors usually don't like it at all, so we always give the Guardian medical control and tell the doctors that. I STRONGLY recommend this and if you can get a medical person to be your guardian it's even better.

BTW, before John can order his battery of 155 cannons to fire it takes four closed loop confirmations. This is not because they don't trust John. It is because the Marines have shelled themselves far too many times by accident, violating the directive "Don't get some of my Marines killed." John reports that while he's never personally made an error that was caught by the system, he has already (in two years) seen two times when the system worked. I suppose it would be a bit like a doctor laying out the operation pre-op for another doc and then asking if they thought that made sense. Four times!

Our family always has someone to watch over the process. Usually Susan who is excellent at researching stuff (former newspaper reporter.) I watch over her. I fired her first oncologist. The one we have now is wonderful. We take full responsibility for our own health care, doctors are consultants.

[LarryHoward]

I have no experience with risk management, but understand that commercial flying in the US is the gold standard in terms of low rate of accidents and injury (I read that it is generally lower than statistically possible). Airlines and pilots have legal protection limiting collection and damages and also have an error review system that works. I don't see anything to suggest that the connection between these two facts is not important. Medicine deserves the same.

This is an important comparison and let us not forget that there is another profitable and influential industry selling insurance insurance and legal services to defendants and plaintiffs in medical negligence actions. Legal protections for physicians and institutions would cut into this. However, health care may also be intrinsically more dangerous than commercial aviation.

Another factor might be that the pilot dies along with his passengers, if (s)he screws up. I bet that fact, in and of itself, eliminates some error.

This plus aviation operates with a strict prohibition against using safety data/investigation info for punitive purposes or legal recourse. Anything releases to safety investigator is privileged. It's very much in the public interest for safety lapses to be fully and truthfully investigated. Refusing to cooperate is one quick way to lose your ticket. When I entered Navy Flight Training, the odds were that 1 in 3 who made it a career would die in an airplane - very few in combat. It's substantially better now due to a very strong safety culture that starts with identifying and addressing safety lapses or errors and looking at the how and why they occurred.

[SemiSalt]

One of the nastier corners of the industry I work in, medical insurance, is comprised of vultures who buy the rights to a block of claims history, and then reprocess the yes/no decisions on paying claims. On a long average, they reverse 5-7% of the claims, implying that that many prescriptions, procedure, where unwarranted, overpriced or otherwise should not have been paid. Or in other words, 1 in 20 was a mistake of some kind. A lot would be for treatment later deemed unnecessary or contra-indicated. Antibiotic for ear ache, maybe.

Of course, it's a scam to a some degree, but it must be supported by a lack of unanimity about what constitutes proper care.

[Orestes Munn]

This plus aviation operates with a strict prohibition against using safety data/investigation info for punitive purposes or legal recourse. Anything releases to safety investigator is privileged. It's very much in the public interest for safety lapses to be fully and truthfully investigated. Refusing to cooperate is one quick way to lose your ticket. When I entered Navy Flight Training, the odds were that 1 in 3 who made it a career would die in an airplane - very few in combat. It's substantially better now due to a very strong safety culture that starts with identifying and addressing safety lapses or errors and looking at the how and why they occurred.

Is the difference that health care providers and organizations can hide their mistakes more easily?

[kdh]

Don't ever underestimate the power of these entrenched industries. They have executed classic "regulatory capture" and proved just how powerfully they could defend themselves during Bill Clinton's presidency as they crushed a very good proposal for restructuring health-care made by Hillary's committee.

I know little of Hillary's proposal other than it was "universal care." Whatever it was even Obama claimed Obamacare is a lot closer to Romneycare.

My sense of it is that the strategy was wrong. Someone unelected squirreled away deciding what was best for us. A classic case of a president overestimating his powers. The assurance from Bill that "you get Hillary too" was not sufficient for our trust. I imagine Hillary learned a lot from the experience.

[Olaf Hart]

Interesting summary of the no fault compensation process, from the Oz perspective.

No clear link from this to quality assurance programs at the moment, but reliable data should provide a path to QA systems.

https://www.mja.com.au/journal/2012/197 ... ng-overdue

[Orestes Munn]

Interesting summary of the no fault compensation process, from the Oz perspective.

No clear link from this to quality assurance programs at the moment, but reliable data should provide a path to QA systems.

https://www.mja.com.au/journal/2012/197 ... ng-overdue

Good article.

[BeauV]

Don't ever underestimate the power of these entrenched industries. They have executed classic "regulatory capture" and proved just how powerfully they could defend themselves during Bill Clinton's presidency as they crushed a very good proposal for restructuring health-care made by Hillary's committee.

I know little of Hillary's proposal other than it was "universal care." Whatever it was even Obama claimed Obamacare is a lot closer to Romneycare.

My sense of it is that the strategy was wrong. Someone unelected squirreled away deciding what was best for us. A classic case of a president overestimating his powers. The assurance from Bill that "you get Hillary too" was not sufficient for our trust. I imagine Hillary learned a lot from the experience.

Hillary was VERY naive back then. She proposed a simple, and obviously better, single-payer system.

Needless to say, many people's oxen were gored! The response was predictable. "We paid for that Congress, by god they're going to do what we tell them!" Hillary's rational proposal was killed immediately.

Yes, the strategy was wrong - both Clinton's were very arrogant in that era. Neither is now. This is the benefit of experience. The downside of experience is that folks know what they can get away with.

[BeauV]

Interesting summary of the no fault compensation process, from the Oz perspective.

No clear link from this to quality assurance programs at the moment, but reliable data should provide a path to QA systems.

https://www.mja.com.au/journal/2012/197 ... ng-overdue

If memory serves: New Zealand voters agree to give up the right to sue for personal injury in exchange for a universal public health system.

It seems that one can pay for universal public healthcare by getting rid of the added expense of everyone suing everyone over personal injust.... who knew??

Seems like a good idea to me!!

[LarryHoward]

Interesting summary of the no fault compensation process, from the Oz perspective.

No clear link from this to quality assurance programs at the moment, but reliable data should provide a path to QA systems.

https://www.mja.com.au/journal/2012/197 ... ng-overdue

If memory serves: New Zealand voters agree to give up the right to sue for personal injury in exchange for a universal public health system.

It seems that one can pay for universal public healthcare by getting rid of the added expense of everyone suing everyone over personal injust.... who knew??

Seems like a good idea to me!!

As long as the AMA will support identifying and eliminating bad doctors. In other words you need a robust and effective quality program. Aviation does. A pilot who has repeated incidents or fails periodic check rides doesn't getting keep flying.

[Olaf Hart]

I have seriously considered moving to NZ if I wanted to continue practising, rather than retire.

It's amazing how much fear of litigation sours a great profession.

I reckon we could halve our health care costs, and possibly improve our outcomes, if everyone practised the way I was taught to 45 years ago.

No evidence, just a gut impression.

[Orestes Munn]

Interesting summary of the no fault compensation process, from the Oz perspective.

No clear link from this to quality assurance programs at the moment, but reliable data should provide a path to QA systems.

https://www.mja.com.au/journal/2012/197 ... ng-overdue

If memory serves: New Zealand voters agree to give up the right to sue for personal injury in exchange for a universal public health system.

It seems that one can pay for universal public healthcare by getting rid of the added expense of everyone suing everyone over personal injust.... who knew??

Seems like a good idea to me!!

As long as the AMA will support identifying and eliminating bad doctors. In other words you need a robust and effective quality program. Aviation does. A pilot who has repeated incidents or fails periodic check rides doesn't getting keep flying.

The AMA, to the extent that it has any teeth as a lobby anymore, does support this in principle. Getting rid of bad docs is a function of state medical boards, many of which, including mine in Massachusetts, are very strict.

[Ish]

I have seriously considered moving to NZ if I wanted to continue practising, rather than retire.

It's amazing how much fear of litigation sours a great profession.

I reckon we could halve our health care costs, and possibly improve our outcomes, if everyone practised the way I was taught to 45 years ago.

No evidence, just a gut impression.

That's exactly what Lewis Thomas said several times in his books. Especially in his book on medicine, "The Youngest Science". Brilliant man, exceptional teacher.

[floating dutchman]

Interesting summary of the no fault compensation process, from the Oz perspective.

No clear link from this to quality assurance programs at the moment, but reliable data should provide a path to QA systems.

https://www.mja.com.au/journal/2012/197 ... ng-overdue

If memory serves: New Zealand voters agree to give up the right to sue for personal injury in exchange for a universal public health system.

It seems that one can pay for universal public healthcare by getting rid of the added expense of everyone suing everyone over personal injust.... who knew??

Seems like a good idea to me!!

Yea, you basically got the nuts and bolts of it right, It's a system that works for us and I like how it works.

About the doctors making a mistake thing, has been discussed here at work with reference to the Masters of our ships, Attitudes in years gone by were that you never questioned the Masters decision, ever. Now days, if you are polite and have good reason to question a Masters decision, even if you are wrong and from a much lower rank no harm will come. Simple mistakes get picked up this way and life goes on.
Apparently Doctors, or more surgeons are looking in this "anyone can question" type leadership to prevent mishaps.
I'd expect that if nurses can freely question a surgeon (apparently that's a big no no at the moment) then incident rates will drop.
Of course this is talk from the mess room and could be quite wrong on a few points.

Jeroen.

[kdh]

[Orestes Munn]

Again, this isn't about judgment, skill, or the monumental fuckup, but procedural glitches and omissions by competent, good faith, actors that end up damaging or killing people. The big question for me is why we can (or, maybe even, want to) fix this for aviation, but not medicine.

[Tucky]

Because the aviation system was put in place a long time ago.