When the healthcare system learns from its’ mistakes
Take a walk around a hospital and more than a few patients will report a medical error horror story that is either responsible for their ailment or has complicated their ailment exponentially. Perhaps most frustrating to patients and families is the system rarely offers full, “this is entirely our fault” apologies, even in some of the more blatant cases of wrongdoing. Half-hearted explanations like “it was a gray area” or “we sort of dropped the ball on this one,” lack the sincerity and candor patients and families desire.
A few days ago the Wall Street Journal’s Laura Landro wrote a piece highlighting the tragic case of Kaelyn Sosa an 18 month old who lost her life to medical error and the hospital that decided to react appropriately. An excerpt:
“As often happens after medical accidents, the facility settled with the Sosa family for an undisclosed sum. But the hospital went further. Administrators analyzed the chain of events that led to the tragedy. They put in place new measures aimed at preventing the mistakes that injured Kaelyn from recurring and to better respond when something does go wrong. The hospital then engaged the child’s parents in educational efforts to underline to medical staff the critical importance of patient safety.”
The hospital deserves praise for redeeming itself in the way that matters, doing its’ best to make sure this mistake is not repeated. And as far as the girl’s mother becoming a community liaison and serving on the hospital patient safety committee, that’s just exceptional and strong and inspiring.
A few thing from the WSJ article. It reports medical errors kill as many as 98,000 Americans each year and notes the figure is according to the Institute of Medicine. To be fair to healthcare professionals, the statistic was gathered nearly a decade ago in the 1999 report To Err is Human. The report officially states “At least 44,000 people, and perhaps as many as 98,000 people, die in hospitals each year as a result of medical errors that could have been prevented…” Let’s hope those numbers have fallen a bit in the last 10 years, and that the actual number of preventable deaths was on the lower end of those estimations.Although reports like this one, seem to point heavily towards the contrary.
My take is this. Over the last two months I’ve spent my time immersed in the healthcare industry. If it wasn’t the hospital, it was clinics, or at the lab for blood draws. My personal care has been exceptional, and most of the healthcare professionals I interact with do their best to serve their patients. My gripe has never been with a specific individual or clinic, or hospital. My gripe is with the system as a whole—it’s lack of transparency, lack of innovation, endless red tape, adherence to mindless protocol, fragmentation of care and the inadequate communication these different deficiencies support. The baby girl from the above WSJ article died not becauseone individual made a mistake—as long as humans are running the show this will happen—-but because the system does a poor job of checking itself.
In the past, we’ve talked here,about applying rules to prevent human error in care—whether it be the three times rule among healthcare professionals, or patients asking more questions,or just doing everything in your power to ensure you are a more informed patient. These are ideal, and I’m not naive enough to think every person who presents to an emergency room or doctor will operate ideally. There comes a point where you are handing yourself, or a friend, or a family member over to the system and just saying “help, please do your best to help.” It is not naive to expect the system to respond accordingly.
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