"Doctors make mistakes" - TED talk

Rick Dagless

http://www.ted.com/talks/brian_goldman_doctors_make_mistakes_can_we_talk_about_that.html

"Every doctor makes mistakes. But, says physician Brian Goldman, medicine's culture of denial (and shame) keeps doctors from ever talking about those mistakes, or using them to learn and improve. Telling stories from his own long practice, he calls on doctors to start talking about being wrong"

Interesting talk.

Squeaky the Squirrel

Thread reminds me of story I read from...Israel or somewhere out there about Doctors going on strike and the death rate dropping something huge, like 40% or something.

Squeaky the Squirrel

When Doctors Go On Strike Patients Stop Dying

gctest50

Squeaky the Squirrel wrote: »

When Doctors Go On Strike Patients Stop Dying

Bit like your local builder saying it's great his van isn't using much diesel these days...

ThatDrGuy

Rick Dagless wrote: »

http://www.ted.com/talks/brian_goldman_doctors_make_mistakes_can_we_talk_about_that.html

"Every doctor makes mistakes. But, says physician Brian Goldman, medicine's culture of denial (and shame) keeps doctors from ever talking about those mistakes, or using them to learn and improve. Telling stories from his own long practice, he calls on doctors to start talking about being wrong"

Interesting talk.

Its more due to lawyers culture of suing you for every damn thing. Mistakes happen, they are guaranteed. In countries where its medico-legally possible there are morbidity and mortality conferences where doctors examine what went wrong and discuss lessons learned from it. Check out some of the onion parodies of TED talks, very good ( esp the social media one )

Xeyn

Squeaky the Squirrel wrote: »

Thread reminds me of story I read from...Israel or somewhere out there about Doctors going on strike and the death rate dropping something huge, like 40% or something.

Emergency services inevitably stay the same even during a strike. Patients who would have attended a hospital only to die of natural causes during the stay, would be at home and the same occurs only the statistic is reported under a different section. Elective surgeries with high risk patients with unavoidable mortalities don't occur for the same statistics. All those stories and reports have zero bearing on the efficacy of the health services they were researching, they were simply reporting numbers.

take everything

Rick Dagless wrote: »

http://www.ted.com/talks/brian_goldman_doctors_make_mistakes_can_we_talk_about_that.html

"Every doctor makes mistakes. But, says physician Brian Goldman, medicine's culture of denial (and shame) keeps doctors from ever talking about those mistakes, or using them to learn and improve. Telling stories from his own long practice, he calls on doctors to start talking about being wrong"

Interesting talk.

Brilliant.
A pet peeve of mine.
The culture of not talking about mistakes, about never admitting being wrong. One of the reasons i'm so ambivalent about Medicine. It infuriates me.

My sister, on the other hand, a pretty good physician (probably better than most) that i have great respect for, but is what i term a kool-aid doctor. Blindly following all aspects of medicine and its culture.
She hates when i question stuff, hates when i talk about being wrong, about not knowing stuff, about the difficult stuff in Medicine.

And i've known so many people like this from Medical school up.
I remember one guy in medical school who knocked over a chest drain canister when we were taking histories. He panicked and thought about scarpering- I had to drag him back to the bedside to sort it out.
This "career is paramount, career is paramount, cannot even entertain the notion of being wrong" bull****.
/rant

Sitric

take everything wrote: »

Brilliant.
A pet peeve of mine.
The culture of not talking about mistakes, about never admitting being wrong. One of the reasons i'm so ambivalent about Medicine. It infuriates me.

My sister, on the other hand, a pretty good physician (probably better than most) that i have great respect for, but is what i term a kool-aid doctor. Blindly following all aspects of medicine and its culture.
She hates when i question stuff, hates when i talk about being wrong, about not knowing stuff, about the difficult stuff in Medicine.

And i've known so many people like this from Medical school up.
I remember one guy in medical school who knocked over a chest drain canister when we were taking histories. He panicked and thought about scarpering- I had to drag him back to the bedside to sort it out.
This "career is paramount, career is paramount, cannot even entertain the notion of being wrong" bull****.
/rant

There is also a really nasty phrase I've heard surgeons use to describe mistakes "A career defining moment". Even if we had adequate levels of medical staff, mistakes would still happen. You can minimise them through diligence but cannot completely avoid them.

lonestargirl

Sitric wrote: »

Even if we had adequate levels of medical staff, mistakes would still happen. You can minimise them through diligence but cannot completely avoid them.

You should also have a robust, no-blame error reporting system. By analysing the cause of minor errors you can modify processes, increase training and perhaps prevent the same mistake leading to a serious consequence in the future. My institution runs bi-annual briefings on the errors that have occured in the last 6 months and the lessons learned from them. The aim is to have as few as possible serious/critical errors but a relatively large number of minor ones as that suggests that people are reporting things.

El_Dangeroso

lonestargirl wrote: »

You should also have a robust, no-blame error reporting system. .

This, effectively. I would love to see something similar to the CAPA system that originated out of the aviation industry.

Pharmaceutical factories already do this with GMP. Anyone who has worked in one of these environments knows the priority they place on near misses.

I attended a brilliant talk in NUIG from a man who had implemented CAPA procedures in the US military. The talk was about getting this implemented in healthcare. He said if we extrapolated the statistics from the UK (we have zero data on this for Ireland, which is presumably worse) then it is the equivalent of a 737 crashing every month in terms of the number of deaths caused by medical error in this country.

This would never be tolerated in aviation, why is it tolerated in healthcare?

0lddog

Couldnt agree more E D however there is a superb motivator in aviation :

Plane goes down.....person in charge never goes home.
Patient goes down...person in charge,........ (well, you know)

Xeyn

El_Dangeroso wrote: »

This, effectively. I would love to see something similar to the CAPA system that originated out of the aviation industry.

Pharmaceutical factories already do this with GMP. Anyone who has worked in one of these environments knows the priority they place on near misses.

I attended a brilliant talk in NUIG from a man who had implemented CAPA procedures in the US military. The talk was about getting this implemented in healthcare. He said if we extrapolated the statistics from the UK (we have zero data on this for Ireland, which is presumably worse) then it is the equivalent of a 737 crashing every month in terms of the number of deaths caused by medical error in this country.

This would never be tolerated in aviation, why is it tolerated in healthcare?

This sort of comparison has been used in the past unfortunately you can't compare the two. By design airplanes, cars etc are designed to be identical - each and every one. Humans are vastly more complex and each is essentially unique. There simply are no blanket diagnosis to cover a group of symptoms. Each individual is dealt as such whereas vehicles have a maintence book, instructional manual etc which will apply to every one of the same model.
There definitely is always room for improvement but let's compare apples with apples.

sam34

after a patient suicide we always do a 'psychological autopsy', consisting of the team going over the chart with an independent psychiatrist, to identify any areas that could/should have been addressed/done better etc.

(obviously there's a whole debate about not every suicide being a failure of the services, it being considered the natural end-point of severe psych illness, personal autonomy etc etc, but for every suicide that we have we undergo the above process.

it's therapeutic for the team also, some of whom may be very distressed by a suicide. )

El_Dangeroso

Xeyn wrote: »

This sort of comparison has been used in the past unfortunately you can't compare the two. By design airplanes, cars etc are designed to be identical - each and every one. Humans are vastly more complex and each is essentially unique. There simply are no blanket diagnosis to cover a group of symptoms. Each individual is dealt as such whereas vehicles have a maintence book, instructional manual etc which will apply to every one of the same model.
There definitely is always room for improvement but let's compare apples with apples.

The methodology has already been put into place in healthcare environments. I know for a fact that systems already in place in Irish hospitals have CAPA modules specifically designed for healthcare that are not being used. You will never know if an error was the true cause of a death, but you do know the error took place and can take effective action to mitigate future risk. This is not controversial or new in any way. It's just not being implemented.

Flier

Xeyn wrote: »

This sort of comparison has been used in the past unfortunately you can't compare the two. By design airplanes, cars etc are designed to be identical - each and every one. Humans are vastly more complex and each is essentially unique. There simply are no blanket diagnosis to cover a group of symptoms. Each individual is dealt as such whereas vehicles have a maintence book, instructional manual etc which will apply to every one of the same model.
There definitely is always room for improvement but let's compare apples with apples.

Don't quite agree with you there. Once you stick two humans at the pointy end then each airplane/human system becomes unique. Human factors is an area much studied and analysed in aviation, and it really is an area where healthcare could do better. It's usually not the mechanical bits that go wrong (or at least if they do they're usually not the only cause of the accident).

echo beach

Xeyn wrote: »

This sort of comparison has been used in the past unfortunately you can't compare the two. By design airplanes, cars etc are designed to be identical - each and every one. Humans are vastly more complex and each is essentially unique.

That is true but the same errors happen over and over again, e.g drugs given by the wrong route or a ten times overdose given because the decimal point is in the wrong place. These are the ones that can and should be 'designed' out of the system.
There will still be unavoidable errors but that isn't a reason not to get rid of the avoidable ones. One way to do that is to use methods that have been shown to be successful in other areas. If those methods work in medicine, that's great; if they don't others will be needed.

gctest50

sam34 wrote: »

after a patient suicide we always do a 'psychological autopsy', consisting of the team going over the chart with an independent psychiatrist, to identify any areas that could/should have been addressed/done better etc.

(obviously there's a whole debate about not every suicide being a failure of the services, it being considered the natural end-point of severe psych illness, personal autonomy etc etc, but for every suicide that we have we undergo the above process.

it's therapeutic for the team also, some of whom may be very distressed by a suicide. )

Is there any mechanism of support for ye at all in a case of patient death ?

( just to keep it simple , say a clear case , wrong route of drug admin or something)

sam34

gctest50 wrote: »

Is there any mechanism of support for ye at all in a case of patient death ?

( just to keep it simple , say a clear case , wrong route of drug admin or something)

not really. I guess there's the employee assistance programme, which is kind of a supportive counselling type programme, but that's not specifically for the aftermath of a death.

realistically, I'd say most people would find a supportive colleague to be of great help.

RobFowl

sam34 wrote: »

after a patient suicide we always do a 'psychological autopsy', consisting of the team going over the chart with an independent psychiatrist, to identify any areas that could/should have been addressed/done better etc.

(obviously there's a whole debate about not every suicide being a failure of the services, it being considered the natural end-point of severe psych illness, personal autonomy etc etc, but for every suicide that we have we undergo the above process.

it's therapeutic for the team also, some of whom may be very distressed by a suicide. )

Thats a very good process. I've been to too many suicides and the memories don't leave you. Along with children I've seen killed in the troubles they are episodes where I can recall every since detail of what occurred and how we treated them.
The last 2 suicides in particular were predicable in retrospect but nothing more could have been done..

Vorsprung

gctest50 wrote: »

Is there any mechanism of support for ye at all in a case of patient death ?

( just to keep it simple , say a clear case , wrong route of drug admin or something)

I've never encountered any sort of support structure! I've run about a dozen arrests after hours in the last 6 months, I've managed to have 10 minutes and a cup of tea on about half of those occasions, an acknowledgement from a boss the next morning of what had happened on maybe 2 occasions (fully aware of it I might add), and on no occasion have I had any feedback on what had happened to those people who had died (in terms of post mortem results)!

sam34

RobFowl wrote: »

Thats a very good process. I've been to too many suicides and the memories don't leave you. Along with children I've seen killed in the troubles they are episodes where I can recall every since detail of what occurred and how we treated them.
The last 2 suicides in particular were predicable in retrospect but nothing more could have been done..

yeah, the aftermath of a suicide is quite distressing for the staff involved. the psychological autopsy is therapeutic in that regard, as well as being a review of the service provided and an opportunity to learn and improve.

Xeyn

Flier wrote: »

Don't quite agree with you there. Once you stick two humans at the pointy end then each airplane/human system becomes unique. Human factors is an area much studied and analysed in aviation, and it really is an area where healthcare could do better. It's usually not the mechanical bits that go wrong (or at least if they do they're usually not the only cause of the accident).

No one is arguing that a system can be improved upon here, but the comparison is the pilot is the doctor and the plane is the patient, which no matter how you look t it, is simply not the same.
I'm all for improving the system because it does need improving but statements like 'it wouldn't be allowed in aviation so why should it be allowed in healthcare' doesn't sit right with me because they just aren't the same.

anotherlostie

One of the key problems with an effective error reporting system has already been alluded to - the fear of owning up to the mistake. To take the pharma industry example, if you admit to making a mistake, you might be disciplined, you might even lose your job, but you won't be sued. Health is more emotive because the inputs are patients, not chemicals or other materials.

When the errors are made, then the people assessing them should decide on the root cause - were people trained incorrectly, is something in the business process complicated and causing repeat errors, or is it simply a human performance issue with one person. If it's the first two, then the system can be re-engineered and improved. A good high profile example of hospital error proofing is discusssed here
http://virginiabeach.legalexaminer.com/medical-malpractice/preventable-medical-malpractice-revisiting-the-dennis-quaid-medicationhospital-error-case.aspx

But I'd guess a lot of the mistakes are made due to human error and if the true cause of these is that the person is overworked, under too much pressure etc. then I doubt hospital management would actively encourage this factor being highlighted?

magicherbs

sam34 wrote: »

after a patient suicide we always do a 'psychological autopsy', consisting of the team going over the chart with an independent psychiatrist, to identify any areas that could/should have been addressed/done better etc.

question how independent the psycfhiatrist is. When his pt dies do you independently go over his file and when your patient dies, he does the same for you. Wouldn't install me with a strong sense of transparency. Especially as I presume the question isn't - did we do everything we could to prevent this but is rather - did we do what was reasonably expected? two different questions.

Flier

Xeyn wrote: »

...but the comparison is the pilot is the doctor and the plane is the patient, which no matter how you look t it, is simply not the same.

I don't think anyone thinks that they are the same. Of course they aren't! And the comparison isn't that the pilot is the doctor and the plane the patient. I think part of the reason why safety culture in aviation works quite well is that the whole system is looked at - from the aircraft and all it's bits, the pilots and cabin crew, engineers, loaders, management, regulatory bodies, etc - anybody you can think of who has any involvement. And of course the 'no blame culture' is vital. Pilots can and do report their own errors so that lessons can be learned. Air accident investigation units spend huge amounts of time and money investigation the minute detail of what went wrong in various accidents and incidents. They don't do it as a retrospective - the primary reason is to find weaknesses so that further accidents can be prevented. The advice to 'learn from other people's mistakes because you'll rarely live long enough to learn from your own'. In the healthcare setting, people don't report their errors, they hide them and nobody learns anything, and so the same thing happens the next day. There really isn't much of a 'safety culture' in medicine at all.

Xeyn

Flier wrote: »

I don't think anyone thinks that they are the same. Of course they aren't! And the comparison isn't that the pilot is the doctor and the plane the patient. I think part of the reason why safety culture in aviation works quite well is that the whole system is looked at - from the aircraft and all it's bits, the pilots and cabin crew, engineers, loaders, management, regulatory bodies, etc - anybody you can think of who has any involvement. And of course the 'no blame culture' is vital. Pilots can and do report their own errors so that lessons can be learned. Air accident investigation units spend huge amounts of time and money investigation the minute detail of what went wrong in various accidents and incidents. They don't do it as a retrospective - the primary reason is to find weaknesses so that further accidents can be prevented. The advice to 'learn from other people's mistakes because you'll rarely live long enough to learn from your own'. In the healthcare setting, people don't report their errors, they hide them and nobody learns anything, and so the same thing happens the next day. There really isn't much of a 'safety culture' in medicine at all.

You are quite wrong there. There is undoubtedly a big scope for improvement in the healthcare sector regarding safety but policies and protocols exist for almost everything which has everything to do with safety. It's endemic. However a big driver for this is defensive medicine which is driven by a litigious population which as has been eluded to here, is yet another huge difference in the two sectors. Defensive medicine has become a necessity in Ireland. It's not usually hold standard clinical and scientific practice, it's practice that is least likely to get you sued. This is a huge drain on financial and human resources.
Every single doctor has to have insurance to protect them from litigation - highlighting the environment doctors have to work under every day. Few if any professions have to deal with this.
The healthcare can look at other industries like the aviation industry, for inspiration, but again the point I've been making is you can't say errors made in aviation should be treated the same as errors made in healthcare. They aren't the same.

On the original topic, one can understand the way current healthcare culture has evolved the way it has but it's certainly time to change.

Flier

I don't see how I'm quite wrong. Airlines have massive insurance policies, and airlines and pilots certainly aren't immune to litigation. Every word a pilot speaks, and every input he makes to his aircraft is recorded - now that is quite an environment to work in don't you think. Lots of other professions are obliged to have insurance. Medics are not unique. Being open to litigation really has nothing to do with how we should tackle safety issues. If anything, it should make us want to improve standards. Having policies and protocols in place is only one spoke of the wheel. Don't get complacent and think that that implies there is a working safety culture. I think one of the biggest problems in healthcare is that noone really knows the extent of errors and mistakes. Most errors don't cause a huge amount of morbidity, but the point is that the same error in a slightly different circumstance might be catastrophic. I agree, the emergence of 'defensive medicine' is bad for medicine and it's bad for patients. A doctors priority should be to do the best for his patient, not what's least likely to get him sued (although most of the time it should be the same).

Xeyn

Flier wrote: »

snip.

No one said doctors were unique. No one said that the safety implementations were perfect and didn't need improving. No one said that litigation should be a primary consideration in safety.
We will simply have to agree to disagree here.

As stated again and again, there is a huge scope for improvement.
I agree small mistakes in one set of circumstances could be a massive one in another.
We'll have to leave it at that!

drkpower

Xeyn wrote: »

You are quite wrong there. There is undoubtedly a big scope for improvement in the healthcare sector regarding safety but policies and protocols exist for almost everything which has everything to do with safety. It's endemic.

Policies/guidelines etc do indeed exist for many things in medicine. But policies and guidelines cannot speak to a cultural change; and that is what is required. And those changes must be supported actively by management (and I include amongst that the higher echelons of the profession itself). There is no real culture in medicine of disclosure of errors, followed by non-judgmental investigation of what led to those errors. In aviation there is; medicine can learn from that. There is no real culture in medicine that encourages those who are genuinely ill to admit same and to stay at home. In aviation there is (in fact, if you turn up sick, you are in serious sh!t!); medicine can learn from that. They are just two examples, there are more; aviation and medicine are not the same, but some similar principles apply and medicine

Xeyn wrote: »

However a big driver for this is defensive medicine which is driven by a litigious population which as has been eluded to here, is yet another huge difference in the two sectors. Defensive medicine has become a necessity in Ireland. It's not usually hold standard clinical and scientific practice, it's practice that is least likely to get you sued. This is a huge drain on financial and human resources.

The supposed litigious nature of Irish medicine is vastly exaggerated. There are in the region of 100,000 adverse clinical incidents annually in Irish medicine. Now of course, not all of those are accompanied by negligence but when you consider that there are not much more than 500 medical negligence cases taken against the state each year, you can see that the rate of litigation to adverse event (0.5%) is remarkably low. As a rule of thumb, for every 200 adverse clinical incidents a doctor is involved in, he will get sued once.

I have never seen anything to indicate that Irish medical litigation rates are higher than other comparable (common law) countries. There is however a massive perception within the profession that that is the case. And personally I think that that perception contributes to the cultural fear of reporting.

Xeyn wrote: »

Every single doctor has to have insurance to protect them from litigation - highlighting the environment doctors have to work under every day. Few if any professions have to deal with this.
The healthcare can look at other industries like the aviation industry, for inspiration, but again the point I've been making is you can't say errors made in aviation should be treated the same as errors made in healthcare. They aren't the same.

Almost every profession requires insurance in respect of potential litigation; solicitors, accountants, actuaries, restaurant owners, hotel owners, small business owners, you name it. So doctors are no different (except that in the case of doctors operating in public Hospitals, their insurance is provided by the state).

Xeyn wrote: »

On the original topic, one can understand the way current healthcare culture has evolved the way it has but it's certainly time to change.

+1

Xeyn

I suggest you read my posts in their entirety. No where did I say we can't learn from other sectors. Infact I stated the exact opposite - I'm implicitly stated that medicine can take inspiration from the aviation industry.

Regardless of whether you think the threat of litigation in this country is real or perceived is completely irrelevant, as to the actual atmosphere at ground level as well as the way it drives policy in the upper levels.

If you can't accept that the aviation industry which deals with humans flying manufactured planes, and the healthcare industry where humans deal with humans, are different then there is wry little point arguing.

I will state quite plainly. Things need to change in medicine but a cut and paste solution from a completely different industry is simply naive.

palmcut

Another possibility to consider is the role of regulators. It appears that when errors are reported they may end up being considered by "fitness to practice" committees as part of the regulatory process.
A "fitness to practice" hearing is extremely stressful, legalistic and expensive; and may end up restricting the future role of anyone appearing before such a committee.

Xeyn

palmcut wrote: »

Another possibility to consider is the role of regulators. It appears that when errors are reported they may end up being considered by "fitness to practice" committees as part of the regulatory process.
A "fitness to practice" hearing is extremely stressful, legalistic and expensive; and may end up restricting the future role of anyone appearing before such a committee.

A very sensible suggestion. I can't see the culture of blameless error reporting coming to the fore with the fitness to practice committee hanging over the heads of healthcare professionals.

drkpower

Xeyn wrote: »

I will state quite plainly. Things need to change in medicine but a cut and paste solution from a completely different industry is simply naive.
If you can't accept that the aviation industry which deals with humans flying manufactured planes, and the healthcare industry where humans deal with humans, are different then there is wry little point arguing

And noone is suggesting a cut and paste solution from a completely different industry.
And noone is suggesting that the aviation and healthcare industries are the same.

Xeyn wrote: »

Regardless of whether you think the threat of litigation in this country is real or perceived is completely irrelevant, as to the actual atmosphere at ground level as well as the way it drives policy in the upper levels..

Surely the facts as to the incidence of litigation is relevant. Or at least, it is important that those facts are better known.

The atmosphere at ground level is exactly what I am talking about. There is a misperception amongst doctors (at all levels, tbh) that people are being sued left, right and centre. That, in my view, leads them to go into a self protection mode; dont admit mistakes or i'll get sued, and my career will be over/adversely affected. Surely it is better that doctors have a true understanding of the position; it might encourage them to admit mistakes and to be active participants in an open honest risk management system that might achieve something, rather than to see risk management processes as something that pen-pushers do and which only seeks to add beureaucratic red-tape to their work.

Then there is the atmosphere that pervaded medicine in my day (and I still think it persists); dont admit you are out of your depth - or sick - or in trouble - because that either projects weakness, or worse still, results in a colleague having to do your work for them.

These are two examples of what needs to change; and medicine can learn from other industries where safety takes precedence, like aviation. Of course, these changes must be led by management (there is no good insisting that doctors dont turn up to work when sick if there really is noone to take their place) but doctors have to step up to the plate as well.

gctest50

Another aspect to errors :

Junior doctors often work crazy hours

Over anybody they should/would know that this leads to (sometimes fatal) errors

Be vaguely equivalent to a taxi driver working after a few drinks ?

drkpower

palmcut wrote: »

Another possibility to consider is the role of regulators. It appears that when errors are reported they may end up being considered by "fitness to practice" committees as part of the regulatory process.
A "fitness to practice" hearing is extremely stressful, legalistic and expensive; and may end up restricting the future role of anyone appearing before such a committee.

This is a good point.

Right now, if errors are reported within the context of a risk management system, they are potentially discoverable in future litigation (and regulatory inquiries). This mitigates agaisnt honest reporting (particularly when there is a misconceived view that one is very likely to be sued in Ireland for a medical errror).

In some other jurisdictions, adverse incident reporting attracts legal privilege and therefore practitioner may be more likely to participate honestly and openly.

Xeyn

drkpower wrote: »

And noone is suggesting a cut and paste solution from a completely different industry.
And noone is suggesting that the aviation and healthcare industries are the same.


Surely the facts as to the incidence of litigation is relevant. Or at least, it is important that those facts are better known.

The atmosphere at ground level is exactly what I am talking about. There is a misperception amongst doctors (at all levels, tbh) that people are being sued left, right and centre. That, in my view, leads them to go into a self protection mode; dont admit mistakes or i'll get sued, and my career will be over/adversely affected. Surely it is better that doctors have a true understanding of the position; it might encourage them to admit mistakes and to be active participants in an open honest risk management system that might achieve something, rather than to see risk management processes as something that pen-pushers do and which only seeks to add beureaucratic red-tape to their work.

Then there is the atmosphere that pervaded medicine in my day (and I still think it persists); dont admit you are out of your depth - or sick - or in trouble - because that either projects weakness, or worse still, results in a colleague having to do your work for them.

These are two examples of what needs to change; and medicine can learn from other industries where safety takes precedence, like aviation. Of course, these changes must be led by management (there is no good insisting that doctors dont turn up to work when sick if there really is noone to take their place) but doctors have to step up to the plate as well.

I can't disagree with what you've said mate.

Xeyn

gctest50 wrote: »

Another aspect to errors :

Junior doctors often work crazy hours

Over anybody they should/would know that this leads to (sometimes fatal) errors

Be vaguely equivalent to a taxi driver working after a few drinks ?

Some studies suggest sleep deprivation might be worse than being legally over the limit.
Mistakes are simply an inevitability under those circumstances.

opinion guy

Xeyn wrote: »

This sort of comparison has been used in the past unfortunately you can't compare the two. By design airplanes, cars etc are designed to be identical - each and every one. Humans are vastly more complex and each is essentially unique. There simply are no blanket diagnosis to cover a group of symptoms. Each individual is dealt as such whereas vehicles have a maintence book, instructional manual etc which will apply to every one of the same model.
There definitely is always room for improvement but let's compare apples with apples.

Beyond wrong.
You NEED to read this:
http://www.amazon.com/Checklist-Manifesto-How-Things-Right/dp/0312430000

gctest50

To keep the aerobunnies happy :

"98,000 patients are killed annually by medical errors"


"That's like TWO 737 crashing every day for a whole year"

http://98000reasons.org/


.

opinion guy

gctest50 wrote: »

To keep the aerobunnies happy :

http://98000reasons.org/

The what now ?

gctest50

The avoidable "errors" like :


"Lauren Lollini of Denver, Colorado, went to a Denver hospital for kidney stone surgery in February of 2009. Six weeks later, Lollini’s health began to deteriorate with feelings of exhaustion and a loss of appetite. After a week of her illness, she became jaundiced and had an inflamed liver. The doctors at an urgent care clinic diagnosed her with hepatitis C. Thirty-five other patients became infected with Hepatitis C at the hospital. A state investigation revealed that the outbreak began with a hospital staff person who had used hospital syringes and painkillers for drug use."

http://98000reasons.org/realstories/story7.html

Lovely. As if doctors don't operate under tricky enough conditions already

Vorsprung

In fairness, that's less of an avoidable medical error and more of a criminal act.

gctest50

Vorsprung wrote: »

In fairness, that's less of an avoidable medical error and more of a criminal act.

For sure.

still leaves 97,000 others

"Blake Fought of Blacksburg, Virginia, was a 19-year-old with an illness that required that he be hospitalized and given liquids and nutrition through an IV line placed through his neck.
When he had recovered from his illness and was ready to go home, the hospital sent a nurse to remove the IV line.
Unfortunately, the nurse had never been properly trained to remove such a line and she did not follow proper procedure.
When Blake began to gasp for air, the nurses failed to respond, telling Blake he was anxious and needed to calm down.
Due to the improper procedure, a bubble of air had entered Blake’s blood vessels and traveled to his heart.
In front of the nurses and his own parents, who were there to take their son home, Blake asphyxiated and died."

Flier

opinion guy wrote: »

Beyond wrong.
You NEED to read this:
http://www.amazon.com/Checklist-Manifesto-How-Things-Right/dp/0312430000

This is the article that the book is based on - makes a very interesting read.
http://www.newyorker.com/reporting/2007/12/10/071210fa_fact_gawande?currentPage=1

Xeyn

opinion guy wrote: »

Beyond wrong.
You NEED to read this:
http://www.amazon.com/Checklist-Manifesto-How-Things-Right/dp/0312430000

Well constructed arguement. Rather lack thereof.
Point out one single statement in the quote of mine that's incorrect nevermind 'beyond wrong'.

opinion guy

Xeyn wrote: »

Well constructed arguement. Rather lack thereof.

I'm not here to argue. Read the book or don't. Educate yourself or don't. You're choice. Either way the guys results prove you wrong. He also specifically addressed the topic of the relative complexitiy of humans and aircraft and large building manufacturing in the book. I'm not typing it all out for you.

Sitric

Flier wrote: »

This is the article that the book is based on - makes a very interesting read.
http://www.newyorker.com/reporting/2007/12/10/071210fa_fact_gawande?currentPage=1[/Quote



This is the actual paper the book is built around:

http://www.nejm.org/doi/full/10.1056/NEJMsa0810119

anotherlostie

opinion guy wrote: »

I'm not here to argue. Read the book or don't. Educate yourself or don't. You're choice. Either way the guys results prove you wrong. He also specifically addressed the topic of the relative complexitiy of humans and aircraft and large building manufacturing in the book. I'm not typing it all out for you.

I would find that a strange attitude on a message board personally. Isn't that a bit like the people in the Humanities forum telling you to read the bible to find the relevance to something they're talking about rather than pointing out the relevant parts?

Squeaky the Squirrel

anotherlostie wrote: »

I would find that a strange attitude on a message board personally. Isn't that a bit like the people in the Humanities forum telling you to read the bible to find the relevance to something they're talking about rather than pointing out the relevant parts?

Time issue is all.

opinion guy

anotherlostie wrote: »

I would find that a strange attitude on a message board personally. Isn't that a bit like the people in the Humanities forum telling you to read the bible to find the relevance to something they're talking about rather than pointing out the relevant parts?

Meh. Experience tells me there is no point arguing with a domatic opinion. MYself and others have provided the necessary evidence. Up to the other poster if he/she chooses to read it and review their dogmatic opinion. The evidence speaks for itself frankly.

Xeyn

opinion guy wrote: »

Meh. Experience tells me there is no point arguing with a domatic opinion. MYself and others have provided the necessary evidence. Up to the other poster if he/she chooses to read it and review their dogmatic opinion. The evidence speaks for itself frankly.

Personally I don't find the need to argue with persons who can only rely on insults to try and assert himself.
I've argued my point and acceded points where they were due. You on the other hand are simply not worth any further effort.