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
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Pat Croskerry
Dalhousie University
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Original Message:
Sent: 04-24-2022 17:28
From: Charles Pilcher
Subject: NYTimes: The Cruel Lesson of a Single Medical Mistake
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.
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Charles Pilcher MD FACEP
Editor, Medical Malpractice Insights - Learning from Lawsuits
https://madmimi.com/p/5f4487
Original Message:
Sent: 04-20-2022 08:04
From: Michael Bruno
Subject: NYTimes: The Cruel Lesson of a Single Medical Mistake
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
Original Message:
Sent: 4/19/2022 7:57:00 PM
From: David Meyers
Subject: NYTimes: The Cruel Lesson of a Single Medical Mistake
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