"Medical Errors---A
Double Edged Sword"
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
over his 35 plus years in
active medical practice. He
is a published author in
Modern Physician, and is
credited as an expert author
by web article directories
and many self help websites
including selfgrowth.com.
Want to learn the strategies
and tactics anyone
can use to get top medical
care? Go there now!
http://www.healthcaresecretsrevealed-finally.com
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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.
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