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	Article  Two "Medical Errors---A Double Edged Sword" By Curt Graham                Why is it that human frailties are the source of human suffering?  Why don't all errors, mistakes, and blunders turn out for the best---instead of the worst?            No one can claim immunity from responsibility just because they're human.  We're all guilty of making errors whether trivial or gigantic.  Medical errors aren't intentional.  Reasonable people understand that--or should!             Medical errors seem to take on a life of their own separate from other categories of errors.  The results of medical mistakes goes to the heart of life--our personal body through which we live life.  It's close and deeply personal!           A medical mistake is defined as, "an error in action, calculation, opinion or judgment caused by poor reasoning, carelessness, or insufficient knowledge relative to medical treatment or advice."                                                                         Webster's Dictionary           An error is a "deviation from correctness and belief in something not true."  A mistake is the act of doing it.  An error is the judgment placed on a mistake. "An error is simply a failure to adjust immediately from a preconception to an actuality."    John Cage             Elimination of medical errors is a team effort!           For example, take medical errors with physician penmanship.  A doctor in a rush scribbles orders on the patient's chart.  It may be carelessness about legibility of the writing, or poor reasoning about the amount of medication needed.  It's not an error or mistake yet!            The doctor may return, realize that he/she wrote illegibly, or that the dosage was too much---and correct the problem.  The moment the nurse interprets the orders, or tries to decipher the handwriting is the critical time.  It's not an error yet!            Good nurses won't accept bad handwriting or medication doses that are outside usual limits.  If she calls the doctor and verifies the doctor's intent, corrects the orders, and dosages, the error is avoided and becomes a non-issue.  So here comes the dilemma.  It's not an error yet!        When the "error in process" reaches the patient---it becomes a true error!           Say the nurse interprets the handwriting herself, or even asks another nurse to agree with her interpretation.  She/he decides that the medication dosage, although out of usual range, is acceptable (because a doctor surely knows what is acceptable).  At the point that the whole process affects the patient directly---it becomes an error.            Who's at fault?            The doctor with poorly handwritten medication errors, and poor medication knowledge or the nurse who should have questioned it all?  Was it a double edged medication error being constructed by two healthcare providers?  I think so.           What about a surgeon during an operative procedure committing a surgical error or using poor judgment?  Is the surgical assistant at fault and committed an error by not confronting the surgeon immediately about it?  The assistant by remaining quiet and the surgeon by being careless, both are at fault.            If the assistant surgeon enabled the primary surgeon to "get back on track", no error was committed although it was in process. Medical error issues go much deeper:           Why does a doctor continue to use unreadable handwriting when they know it is a serious problem for nurses to interpret?  It happens all the time, and drives the risk prevention committee nuts! Think about these factors: Any doctor can make their writing legible if they want to.   There is no medical enforcement in hospitals that makes a physician write legibly.  Intimidation doesn't work.   Shoving the responsibility of handwriting interpretation on to the nurses shows physician arrogance and disrespect for other providers and the patient.   Attitude of the physician towards most other medical functions is reflected by the way they handle their handwriting problems.  Sloppy in one--sloppy in them all.   Computerized medical records should resolve most of the medical errors with physician penmanship problem eventually. Sweet revenge might be: Nurses should repeatedly report unreadable doctor's handwriting to hospital committees that discuss such issues, and the committee can even advise that doctor of the dangers and enforcement possibilities.   Nurses should plan to repeatedly call that doctor about illegible orders.  If doctors learn that every time they write orders that are not clear, a deluge of phone calls will follow.  It's one time that nurses are on hallowed ground to do so.   Since medical errors are reportable, a physician who instigates a pattern of repeated poorly handwritten medication errors, will create their own hell.   When poor handwritten orders create medication errors, and results in many mistreated patients, a wise doctor will avoid the issue and write plainly.   Just because handwriting in our school system is no longer a priority, one cannot excuse the bad results of poor handwriting in any profession.           Why is it that a respected doctor with highly praised credentials suddenly one day makes a serious medical error?  Even the best are brought to their knees on occasion.           The slimy process of distraction is my answer.             Any distraction that interrupts another focus of thought is not only irritating, but also can be dangerous.  A pilot that lands his plane with the wheels "up," and the new problem of increased auto accidents while the driver is talking on their cell phone, are good examples of distraction.            Some surgeons are so involved in telling a story at the operating table they forgot where they were in the procedure.  They distracted themselves.  It's true!           Distractions are not always bad (another two edged issue).  The car horn alerts you not to walk out in front of them in traffic. However, medical errors occur most often when a distraction occurs right in the middle of a medical crisis.  You take your eye off the ball for one second, and you lose.           Surgeons inadvertently leave a surgical instrument or other items in the the abdomen for the same reason----distracted in some manner. A factor of two:           When a medical error, medication error, or treatment error occurs, it causes twin jolts.  Not only does it affect the patient, but also the medical provider.            If you believe for a minute that a doctor, nurse, or other provider isn't affected deeply by their own error, then you don't really understand the nature of a caregiver.            Feeling remorse, guilt, blame, self-admonishment, compromise of personal integrity, and self-ridicule, follows every medical doctor and provider who have ever made a medical error.  The greater the compromise it had on the patient, the longer it lasts in memory, and the more often it surfaces in thought.           Reportedly, medical errors cause 98,000 deaths a year in the USA.  What happened to the 98,000 plus medical care providers after committing those errors?  Ever think about that?           What it never mentions in such a report is how deeply it also affects the person causing the error, or contributing to it. It doesn't forgive them, or excuse their mistake.  But the mental punishment still happens.           Do you believe that they think about what they could have done to have prevented it every day for years?  Absolutely!           Are they continuously feeling guilty about it?  Absolutely!            Does it cause doctors and nurses to change professions, feel insecure about their abilities, and avoid similar situations for the rest of their lives?  You bet!  It's a deep permanent scar burned into the brain.            Whether you think about medical errors with physician penmanship or more serious medical errors resulting in the death of a patient, both parties are traumatized.            It doesn't excuse the errors made, or the carelessness of the provider that caused it, but it does result in the gradual improvement of health care delivery by development of strategies to avoid those medical errors.  Preventing medical errors is a top priority for all medical services.           Another wonderment I have is how efficient pharmacists are about avoiding poorly handwritten medication errors on prescriptions that are illegible to most of us and presented to them every day.           Where do we park all these medical error reports and how does one manage them on a day to day basis?  A topic for another day. **********         "When Noah sailed the waters blue, he had his troubles same as you; for forty days he drove the ark, before he found a place to park."                                                               Anonymous                                                                                                    The author, Curt Graham, is a retired medical doctor who has written extensively on many topics over his 35 plus years in active medical practice as a specialist in OB-GYN.  He is a published author in Modern Physician, and is credited as a “Platinum Expert author” by EzineArticles.com directory.  Learn incredible healthcare secrets, strategies, tactics, and information that will dramatically improve your personal healthcare.  Go there now!               http://www.HealthCare-Toolbox.com  Please feel free to copy, send, or distribute this article as long as the article is not changed, and the author's resource box is included with the article as written. Copyright 2005, L & C Internet Enterprises, Inc., Curt Graham M.D., All Rights Reserved. Word count = 1351 Keywords = poorly handwritten medication errors,healthcare providers,medical errors with physician penmanship,medical errors,healthcare delivery,medical mistakes,medical treatment,medication errors,treatment error References:   1. http://www.fda.gov/fdac/features/2000/500_err.html  2. http://www.quic.gov/report/ 3. Brennan TA, Leape LL, Laird NM. Incidence of adverse events and negligence in    hospitalized patients. Results of the Harvard Medical Practice Study I. New Engl J    Med.1991;324:370-6. 4. Leape LL. Error in medicine. JAMA 1994;272:1851-57. 5. Schimmel EM. The hazards of hopitalization.    Ann Intern Med 1964;60:100-10. 6. Leape LL, Brennan TA, Laird N, et al. The nature of adverse events in hospitalized     patients: Results of the Harvard Medical Practice Study II. N Engl J Med    1991;324:377-84.  You're Home / Recovery Room / Learn About Us / Contact Us  / Site Map Policies-Disclaimers / Article Archives  /  Subscriber Info
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