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  • 1.  NYTimes: The Cruel Lesson of a Single Medical Mistake

    Posted 04-19-2022 19:57
    As we await the sentence for RaDonda Vaught, this is worth reading & reflecting on.

    The Cruel Lesson of a Single Medical Mistake
    https://www.nytimes.com/2022/04/15/opinion/radonda-vaught-medical-errors.html?referringSource=articleShare


    Sent from my iPhone

    David
    David L Meyers, MD MBE FACEP
    410-952-8782


  • 2.  RE: NYTimes: The Cruel Lesson of a Single Medical Mistake

    Posted 04-20-2022 08:06
    Thanks, David!  

    I think this case is truly a travesty of justice, a disaster for the Quality & Safety movement, and a major setback for patient safety.

    I remember the wisdom of Lucian Leape, M.D., one of the fathers of the Q&S movement in healthcare (triggered by the publication of "To Err Is Human" in the 1990s).  He testified before congress that the #1 obstacle to improving the safety of healthcare in the US is that we punish people for making mistakes.

    Development of the "blameless culture," leading to full error discovery and analysis, is what ultimately made the aviation industry safe.  We in medicine were slowly moving along that path.  This is a major setback.

    Mike



    Michael A. Bruno, M.D., M.S., F.A.C.R.  
    Professor of Radiology & Medicine

    Vice Chair for Quality & Patient Safety

    Chief, Division of Emergency Radiology

    Penn State Milton S. Hershey Medical Center
    ( (717) 531-8703  |  6 (717) 531-5737

    * mbruno@pennstatehealth.psu.edu  

    1571679014277





  • 3.  RE: NYTimes: The Cruel Lesson of a Single Medical Mistake

    Posted 04-20-2022 09:20

     

     

    April 20, 2022

    8:30 AM

    Michael

     

    The Safety Movement in the Aviation Industry was not a blameless environment.  There are numerous cases where it was established that gross negligence on the part of the pilot resulting in a loss of life led to either death of the pilot, loss of the pilot license (ability to fly) or imprisonment in some countries.  It has been less of a penalty for the designers of the aircraft and systems.

     

    For instance, in the case of the B737MAX, the chief Technical Pilot was charged with deception about the aircraft certification and faces many years in prison if convicted.  It appears his actions were not an innocent mistake.  The pilots also paid the ultimate price.  But so far Boeing has only been fined.  And what about the complicit FAA, who ceded their responsibility for insuring Safety.

     

    Fault and error discovery on the part of those related to an aircraft crash has not been forthcoming from the manufacturers or the operators.  A lot of finger-pointing goes on and only the investigations by the NTSB and the FAA (government agencies) tend to discover the real causes.  Remember, at first the Boeing CEO blamed the pilots and said the B737MAX was rock-solid.

     

    The Cockpit Voice Recorder and Flight Data Recorder were added as mandatory systems on commercial airliners because those involved were not self reporting incidents.  Any abnormal aircraft incident MUST now be logged in the aircraft log book and reported to the FAA.

     

    Maybe it is time for a Safety Oversight Function to become independent from the "operators".  I assume the FDA fills the role of insuring the equipment and consumables are Safe, not the manufacturers.

     

       Nelson

     

    TAMARAC LLC

    860-844-0199

    ntoussaint@tamarac.com

     






  • 4.  RE: NYTimes: The Cruel Lesson of a Single Medical Mistake

    Posted 04-24-2022 17:28
    I may be reading Nelson's message wrong, but the NTSB, FAA, ASRS, CAST and even the ALPA (pilots will get it) have done an amazing job of improving patient safety since the 1980's by increasing transparency, encouraging disclosure and immunizing reporters. A former NWA/Delta pilot and airline safety officer who serves on our Board Quality and Safety Committee offers these comments:
    The crime and punishment model advocated has been discredited in aviation for some time. The immunities and collaborative approach built into our aviation safety systems has resulted in a nearly perfect aviation fatality safety record over the past 10 years. While it's true in some countries aviation safety is treated as a criminal matter, there's no evidence this approach yields better results.
    The 737MAX pilot referred to has been exonerated of all charges and there continues to be a robust discussion in the aviation community about the role of pilot error in the MAX crashes.
    Black boxes were added to commercial aircraft because those devices can survive a crash and will yield information that pilots may not be able to provide. Flight operation irregularities are not entered into the aircraft logbook, which is a tool for aircraft maintenance.
    Criminally charging health care providers for med errors will only incentivize providers to hide mistakes, or clam up and lawyer up. We'd be dooming ourselves to repeat the same med errors over and over and fail to learn about underlying systemic causes. Ultimately the patients will pay the price for such an approach.


    ------------------------------
    Charles Pilcher MD FACEP
    Editor, Medical Malpractice Insights - Learning from Lawsuits
    https://madmimi.com/p/5f4487
    ------------------------------



  • 5.  RE: NYTimes: The Cruel Lesson of a Single Medical Mistake

    Posted 04-25-2022 08:48
    Exactly.  Thanks, Charles!

    Additionally, we are currently dealing with a staffing crisis in health care, particularly among nurses, which has been exacerbated by the so-called "Great Resignation" occurring across our economy in all industries.  Treating human error as a crime (punished by prison time and economic ruin) will only exacerbate this problem.  Imagine what would happen if 25% of the nation's nurses left the profession abruptly.

    Mike




    Michael A. Bruno, M.D., M.S., F.A.C.R.  
    Professor of Radiology & Medicine

    Vice Chair for Quality & Patient Safety

    Chief, Division of Emergency Radiology

    Penn State Milton S. Hershey Medical Center
    ( (717) 531-8703  |  6 (717) 531-5737

    * mbruno@pennstatehealth.psu.edu  

    1571679014277





  • 6.  RE: NYTimes: The Cruel Lesson of a Single Medical Mistake

    Posted 04-25-2022 10:46
      |   view attached
    Apologies for unduly labouring this point but the mention of the black box brings it up again. By providing timely, objective and detailed data leading up to the failure, the device has proved to be a great boon to aviation safety. .
    We don't have anything comparable in medicine - the closest we come to it is root cause analysis which is confounded by a variety of problems, but principal among them is our failure to get to the distal cause of the majority of adverse medical outcomes - thinking errors.
    There is now a burgeoning literature that confirms cognition is our biggest problem.
    Although we have strategies that identify proximal clues as to what went wrong (failure to get an adequate history, failure to perform appropriate tests etc.), these focus on behaviour and fall short of identifying the distal, cognitive variables, which are not so tangible or obvious, but are where the meaningful explanations lie.
    Cognitive autopsies (what the clinician was thinking/feeling) are more difficult to do but can be done with appropriate training.
    There is an ethical imperative to put these in place. Understanding that cognition precedes behaviour might result in less inappropriate blaming when things go wrong. 
    Pat Croskerry

    ------------------------------
    Pat Croskerry
    Dalhousie University
    ------------------------------

    Attachment(s)



  • 7.  RE: NYTimes: The Cruel Lesson of a Single Medical Mistake

    Posted 04-25-2022 15:28
    Thanks, Pat.

    Yes, the cognitive lapses are tough to understand.  I suspect many are neuro-biologically mediated, e.g., due to factors out of our control.  Human error seems to be a constant (see the article linked here):


    Ironically, I'm wondering if our patient safety apparatus was the root cause of this (and similar) events?  By adding on multiple layers of protections, following the famous "Swiss-cheese" model, we create systems that are unwieldy and overly burdensome... so people develop ad-hoc work-arounds, which create risk.

    This, to me, is a classic case that the 2nd category of "Just Culture" was intended to address--the inappropriate use of "work-arounds."  

    Under the "Just Culture" model, Vaught should have been coached not to use these work-arounds.  It is not a felony.  It is a lapse of leadership. 

    Mike



    Michael A. Bruno, M.D., M.S., F.A.C.R.  
    Professor of Radiology & Medicine

    Vice Chair for Quality & Patient Safety

    Chief, Division of Emergency Radiology

    Penn State Milton S. Hershey Medical Center
    ( (717) 531-8703  |  6 (717) 531-5737

    * mbruno@pennstatehealth.psu.edu  

    1571679014277





  • 8.  RE: NYTimes: The Cruel Lesson of a Single Medical Mistake

    Posted 04-25-2022 15:42
    Which I mentioned in my earlier message (but forgot to paste the link in the blank that I left for it).  Maybe this is another case in point... is it another good example of a cognitive lapse?   Or just human error??
    Maybe all of the above???

    Anyway, here's the link:


    Balancing the "Human" in Human Errors. These underlying human factors cannot be ignored hoping, for example, that artificial intelligence and related tools will solve the problem, according to Dr. Krupinski.



    Michael A. Bruno, M.D., M.S., F.A.C.R.  
    Professor of Radiology & Medicine

    Vice Chair for Quality & Patient Safety

    Chief, Division of Emergency Radiology

    Penn State Milton S. Hershey Medical Center
    ( (717) 531-8703  |  6 (717) 531-5737

    * mbruno@pennstatehealth.psu.edu  

    1571679014277





  • 9.  RE: NYTimes: The Cruel Lesson of a Single Medical Mistake

    Posted 04-25-2022 15:48
    Speaking as an ER doc of 4 decades and plenty of errors, safety has never been guaranteed and is frequently violated when "guaranteed."
    Tom benzoni





  • 10.  RE: NYTimes: The Cruel Lesson of a Single Medical Mistake

    Posted 04-25-2022 17:58
    If "cognition is our biggest problem", it is because it occurs in the dirty, messy real world where there are biases, distractions, dysfunctional EHRs, production pressures, 2 million new medical research articles expanding medical knowledge each year and a host of other confounding factors and impediments that interfere with its pure expression. We need to get serious about creating conditions & assistance that facilitate humans to exercise cognition safely & effectively. That will be more successful than working to perfect the humans.

    Sent from my iPhone

    David
    David L Meyers, MD MBE FACEP
    410-952-8782





  • 11.  RE: NYTimes: The Cruel Lesson of a Single Medical Mistake

    Posted 29 days ago
    For those interested in the issues raised by this case, the Institute for Safe Medication Practices ISMP) and the Just Culture Company are presenting a discussion on May 6. Here is a link to the registration site: https://ecri.zoom.us/webinar/register/WN_sdx7qFzERamBgXo-h5wv4w

    David
    David L Meyers, MD, MBE, FACEP

    On Apr 19, 2022, at 7:56 PM, David Meyers <dm0015@comcast.net> wrote:

    As we await the sentence for RaDonda Vaught, this is worth reading & reflecting on.

    The Cruel Lesson of a Single Medical Mistake
    https://www.nytimes.com/2022/04/15/opinion/radonda-vaught-medical-errors.html?referringSource=articleShare


    Sent from my iPhone

    David
    David L Meyers, MD  MBE FACEP
    410-952-8782