Here's an article that decries the epidemic of medical error.
Why is it painful? Because now, more than six years after it was written, this article continues to be highly accurate in its description of the mountain of preventable injuries and deaths from medical errors. There hasn't been as much progress as we'd like--nowhere near it.
This epidemic of error, sometimes challenging to see without quality improvement tools, continues in our modern healthcare system...and there's no easy fix--but there are some good ones we need to try. It's a challenge, as a physician, to take a square look at our performance (all of us in the US system) as a healthcare team.
My desire to gauge and improve our current performance (part of which I own as a provider in the system) is what lead me to complete years of Lean and Six Sigma coursework so I could help deploy the well-known tools of quality in our field. This article holds deep meaning for me and so, despite the fact it's pretty tough to read if you practice in the field, I share it here.
Oh yes, there are lots of reasons why our system performs this way...but the bottom line is the bottom line. That makes work like this tough, but important, to read.
Try to remember with me that pretty much no one in healthcare (that I've ever met) works in the field with a plan to harm someone. Almost every single person wants to help patients. That's part of what makes medical error so difficult: it's well-intentioned people working very hard and yet somehow our system continues to produce this level of defect.
Medical errors are complex, and while some have likened them to a model where holes in a piece of cheese are lined up and an error is produced, I think medical errors occur much more in line with the game Frogger: each line of traffic that patients need to navigate has an associated risk...but the situation is fluid and the holes (unlike Swiss cheese) are always moving. (Click here for more on how medical errors are a lot like Frogger.)
Try to keep that in mind when you read this article as it holds up a difficult, but important, unflattering mirror to our level of performance.
Click the link below to spend some time with this entry, recently shared by a healthcare quality colleague (Mark Graban) on LinkedIn, that makes us take a hard look at many of the myths around healthcare quality including my personal favorite myth: "complications make money".
In fact, yes, we are sometimes paid for the increased amount of work we do in taking care of complications (less so nowadays as we go from volume to value payment structures) but the amount of reimbursement we miss out on owing to poor quality is where the real action is--not the government withholds.
Oh, and more importantly than the reimbursement issues, it's the right thing to do to work on improving quality for patients.
The belief that complications make money results from failing to understand the Cost of Poor Quality (COPQ). For more info on the COPQ, click here.
And when you have a minute, read this powerful, sobering article that rings true six years after its release.
...medical professionals now talk freely about the existence of error and loudly about the need for combating it, but silence about the extent of professional inaction and its causes remains the norm...this latest study, which decries the continuing “patient-safety epidemic” while failing to do next what any public health professional would instinctually do: tally up the toll. Instead, we get dry language... Let’s fill in the blanks: If this unchecked “epidemic” were influenza and not iatrogenesis, then from 1999 to date it would have killed the equivalent of every man, woman and child in the cities of Raleigh...and Washington, D.C. Does a disaster of that magnitude really suggest that “further study” and a “refocusing of resources” are what’s needed? Why are we still killing so many patients? Call it the “three I’s”: invisibility, inertia and income...