To Err Is Human
To Err Is Human asserts that the problem is not bad people in health care, rather it is that good people are working in flawed systems that need to be made safer.
Healthcare-related errors are the third leading cause of death in the United States today.
A realization is that many of these errors are out of the clinician’s control. Hospitals are obligated to facilitate, identify and establish root cause analysis of healthcare-related errors. Disclosure of medical errors is considered an ethical duty and is required by JCAHO. Despite all efforts to resolve these issues, a current study from Johns Hopkins University revealed a number of healthcare-related errors have not significantly improved since the report by the Institute of Medicine (IOM) in 1999.
How can you make an impact?
Standard of Care
First and foremost, we need to ensure that the standard of care is met with each patient. We know that if the proper protocols are in place, the safety of the patient increases, and the likelihood of error decreases. Essentially, we need to identify and implement these protocols, as well as improve the policies and procedures across all departments, to help eliminate some of the human errors.
Furthermore, institutions must ensure that patients harmed by adverse events do not face additional financial burdens. If an actual error transpires, the appropriate institutional representative should admit responsibility and develop a plan to prevent the error from reoccurring. They should adopt policies that encourage smooth transitions to new technologies, and foster communication as the key to improving patient safety.
There are instances in the healthcare process when the provider is required to make a critical decision. It is in these critical moments where the safety of the patient is most at risk, and is commonly where the most mistakes are made- and not just in the differential diagnosis. So, we’re going down the wrong path.
We must identify critical decision-making strategies and determine what we can do to improve these decisions. We need to push the standard of care to the highest level that we can deliver.
The goal is to use a team approach; a collaborative effort. We must work together to provide the right diagnosis, right imaging and testing, and the right specialist for each patient. Our role is to be laser-focused on ensuring that every patient receives The Right Care every time.
Kayur V. Patel, MD, MRO, FACP, FACPE, FACHE, FACEP