Medical Mistakes Should be a Learning Moment

Medical Mistakes Should be a Learning MomentIt would take an odd quirk of personality to enjoy making mistakes and undermining responsibility and action. Most people hate making mistakes. And yet, they happen in every field of endeavor.

Healthcare is no exception. The difference is that the ramifications of error can be grave. A Johns Hopkins study suggests that medical errors are the third highest cause of death in the U.S. and may result in the death of 250,000 annually, according to an article from the school.

The twin impacts of feeling the responsibility for someone’s suffering and the potential legal implications of causing injury or death are daunting. Care organizations have often reacted through defensiveness and doctors often fail to publicly point out the mistakes of colleagues.

But the approach to mistakes means that organizations frequently miss opportunities to improve their effectiveness. As Johns Hopkins put it:

The researchers caution that most medical errors aren’t due to inherently bad doctors, and that reporting these errors shouldn’t be addressed by punishment or legal action. Rather, they say, most errors represent systemic problems, including poorly coordinated care, fragmented insurance networks, the absence or underuse of safety nets, and other protocols, in addition to unwarranted variation in physician practice patterns that lack accountability.

Instead of reacting to error as an imperative to protect the organization, care providers could take a different view and endeavor to learn from mistakes instead, as the Wall Street Journal reported.

By looking at patterns of errors in specific types of practices, providers can look for patterns that can increase the chance of something going wrong. In obstetrics, 34 percent of injuries resulted from incorrect selection and management of therapy. Doctors frequently failed to consider which mothers might have conditions that could cause issues in vaginal delivery of larger babies. The physicians might not consider complications like pregnancy-induced high blood pressure or infections in expectant women.

In emergency rooms, physicians frequently performed diagnoses based on intuition or first impressions rather than a more thorough consideration that might take into account other conditions. The doctors often failed to order the right diagnostic tests, did not consider pertinent information from a patient’s record, and then discharged patients too early.

As the Johns Hopkins study noted, problems are often systemic, which means addressing practitioners on an individual basis isn’t the most efficient way to improve treatment and operations. Instead, institutions and their leaders must have the courage to examine their own problems, and those of the industry as a whole, to find the patterns that create danger for patients and institutions alike.

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