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Should we be punishing medical errors?


An interesting story came across my desk recently. Apparently, some states in the U.S. have moved towards a punitive model in trying deal with medical errors and adverse outcomes – this particular story describes how Utah will no longer fund healthcare providers and hospitals for dealing with illnesses that resulted from avoidable errors and infections.

On the surface, it kind of makes sense – one should be punished for making a mistake, right? Other goods and services industries guarantee their work, so why not medicine? But here’s the kicker: since June 2011, when medical errors were “mandated” to be reported, only 17 such events have been disclosed in the whole state of Utah that would potentially fall under this punitive model.

There is absolutely no way that there were only 17 avoidable medical errors in the whole state of Utah over the course of a year.

Healthcare professionals make mistakes. Daily. Medicine is still very much a skill-based profession, and as such is at constant risk for human errors. It is normal. The trouble is, identifying and preventing them is a very complex issue; a process that is still very much in its infancy in the medical field.

The first difficulty is in recognizing when errors occur. Most mistakes made by healthcare professionals go unnoticed because they usually do not lead to an appreciable adverse outcome. Some of you may be familiar with the swiss-cheese model of adverse events; because of the multitude of steps involved in a patient’s care (i.e. different levels of “safeguards”), it usually takes a series of errors to align before an adverse outcome materializes.

Imagine this scenario:

A cancer patient presents to a busy oncology clinic for assessment and initiation of chemotherapy treatment. The physician writes an order for the chemotherapy drug, but the handwriting is suboptimal and it is difficult to make out where the decimal point is in the dosage: is that 0.10 or 1.0? The nurse happens to be a new nurse, who decides to ask a more senior nurse to help decipher the writing, since the physician is already swarmed with an overflowing list of patients. They agree that it most likely is 1.0, and the nurse goes on to set up the infusion pump. Incidentally, the hospital has just switched to a new vendor for its infusion pumps, and all the staff are just learning how to program the machines. The nurse unintentionally enters a dose of 10.0, which is well above the normal limits of this particular chemo – however the machines were not designed to have automatic safeguards to prevent programming of excessive doses. The patient ended up receiving 100x the intended dose of chemotherapy, and passed away shortly after the error(s) were identified too late.

Who’s at fault here? And if it’s more than one individual, how much of the “blame” should each be accountable (and perhaps punishable) for? We now enter the next great difficulty in trying to use a punitive model to address medical errors: the complexity of how errors occur in medicine means that true analysis of them require honest self-reflection and reporting. In other words, the culture of how we view and approach medical errors must first shift away from the traditional shame-based paradigm.

Check out Brian Goldman’s excellent TED talk on this topic:

And this can only happen in a safe and protected environment, where medical mistakes can be openly discussed so that everyone can learn from them. Otherwise things will only get swept under the rug, and you end up with ridiculous numbers like 17 errors in a whole year.

Punishing hospitals and healthcare providers for adverse events will, in my mind, only drive us in the wrong direction in tackling and preventing future medical errors.

Dr. Edmund Kwok is an Emergency Physician with special training and interest in performance management, quality improvement, and patient safety. He blogs at the Front Door to Healthcare.  Follow on Edmund on Twitter @FrontDoor2HC.

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43 comments

  1. Kira

    I have suffered from a medical mistake, an othropedic surgeon inserted 2 screws that were far too long going through my shin and in to my calf muscle during a patella tendon realignment. This error caused permanent irrepairable nerve damage. Furthermore it was recently discovered that the surgeon also failed to fracture the shin bone which is a key piece in attempting to realign the knee. Now on top of all else I am looking at having to have the same surgery again but properly.

    I understand no one is perfect and even doctors can make mistakes but when a doctor denies there was a mistake and refuses to listen to their patients concerns or problems following the mistake they create a monster the patient is forced to live with. In Canada’s healthcare system it took over a year to get in to the office of another orthopedic surgeons who confirmed the diagnosis of my family doctor and I continue to endure the pain he caused. I would be lying if I said I didn’t want 5 minutes alone in a room with that doctor and a hockey stick so that he could endure a small percentage of the pain he caused.

    It never occurred to me to file a complaint or sue, that isn’t how I was raised and I don’t believe either process is an effective culture. We need to find some way to give patients the opportunity to get second opinions or treatment following a mistake. At the end of the day a doctor doesn’t live with their mistakes, the patients and their family does.

    As radical as this may sound it would just be nice if everyone, doctors politicians everyday people acknowledged their mistakes apologies and then try and ensure it isn’t repeated. This used to be common sense, when did that change because I never got the notice.

    • Ryan Herriot

      For what it’s worth, Kira, we are taught to acknowledge and apologize for errors when they occur. Hopefully this will become common practice over time, so others have experiences that are less emotionally (if not physically) painful.

  2. Roy Guharoy

    That will be a shame. Punitive system does not work. I worked in a punitive culture in a New York teaching hospital. There were hardly any reported error. Although, we knew otherwise. Thankfully, we were able to change the culture and transformed it to a non-punitive culture. Then the magic happened and we were able to find so many errors which were hidden under the carpet in he past. Our multi-disciplinary team looked at every reported error and made many system changes leading to significant improvements in patient safety. I am not a proponent of supporting callous incompetent providers. The beauty of a well coordinated non-punitive system system is catching the errors before occurring. Unfortunately, our incompetent politicians and pen pushers do not understand the scenario. They want to maintain the status quo and the patients pay the price..

  3. Kira

    Thank you for your comments and I hope you are right, because far worse then the physical pain was the emotional stress caused by the doctors refusal to acknowledge the problems. Had it not been for a co-worker whose former career was an orthopedic nurse I wouldn’t have known how much trouble I was in.

    When a doctor refuses to acknowledge the problems a patient is having and it takes months or years to get a second opinion you start to question your own sanity. The doctor kept saying if you just strengthen you quad all these pain issues will go away and as a patient you start to wonder if it is you, without support that will drive a patient to or over the edge. That is we’re my concern comes from.

  4. Sara Jones

    We have to be mindful of the fact that recent studies reveal that despite a decade of the “no blame no shame” culture initiated by the 1999 To Err is Human paper , patient safety has not improved.

    http://www.webmd.com/news/20101124/study-no-improvement-in-hospital-safety

    I believe there is sound logic to believe that an admission of human error, a sincere apology and the creation of plans to affect change is effective in some situations but I don’t think this approach applies to all incidents.

    What if the nurse in the example of the medication error was supposed to attach a SAT monitor as per policy but failed to do so? What if a patient dies in surgery in a manner that was avoidable because the team didn’t bother to follow the safe surgical check list even though hospital policy demanded it? What about a unit that has a high rate of infection and a low rate of hand washing compliance? There are times when the right way and the safe way is known to all but not followed. In these cases, I feel that accountability by the clinician and/or the department head and/or the the hospital must exist.

    • Catherine Richards

      I agree with your comments, Sara and I thank you for posting the link. Yours are great examples matched with valid questions about healthcare accountability.

    • catherine mitchell

      I especially appreciated your post, given that work here in Winnipeg shows that medical error is so grossly underreported even in a no blame environment

  5. Catherine Richards

    My comment may not be popular among healthcare providers, but this subject disturbs me. I don’t understand how giving healthcare workers a pass when they make mistakes that affect the life or health of a patient is at all the right thing to do in any context or for any purpose.

    I do understand and appreciate that healthcare professionals are human and that they do and will make mistakes, but I don’t like the suggestion that relieving them of the burden of accepting responsibility for those mistakes is a good idea. If we suggested to murderers that if they simply tell us who they killed, they will feel better, we and others will learn from them not to kill, and their willingness to admit to a murder will protect them from jail, would that be a reasonable strategy to reduce the murder rate? I think you will see how ludicrous that sounds. Why should healthcare professionals need incentives to come clean about their known mistakes? They should tell the truth when a mistake is made or observed simply because it is the right thing to do. They too are patients or family members of patients at times. Would they not expect honesty from their healthcare providers?

    The video attached to this article I have seen before. I responded quite emotionally to the content and while it drew the support of the audience and a standing ovation for the doctor presenting the talk, I was appalled by his admission when he says at the 9:56 point in the video, “…it wasn’t because of my attending, he was a doll, he talked to the family and I’m quite sure that he smoothed things over and made sure I wouldn’t get sued. …” I believe it. As a patient, and as a family member of a loved one who has been harmed by not only some healthcare providers’ mistakes, but by the cover ups and failures to admit to these mistakes, my trust in the integrity of some healthcare professionals and in healthcare oversight authorities has been irreparably damaged. I think a lot of “smoothing over” is going on in healthcare rather than respecting the patient and/or their family’s right to know the truth, especially when things go very badly or a death occurs. Patients and families also deserve to receive an apology when things go terribly wrong and sometimes blame is warranted.

    When I heard the doctor say those damning words in the video, I was not so much shocked as I believe he talks about the true motivator for covering up mistakes which is the fear of legal action, but I felt very sad for Mrs. Drucker and I wondered if after her grieving family was “smoothed over”, were they ever made aware of the truth? I still wonder why as I also worry that these types of deadly mistakes are left to the patient and /or their family to live – or die – with the consequences while the offending healthcare provider lives only with the burden of a guilty conscience and a desire to do better. I agree with Sara Jones, some mistakes are the result of negligence and in these cases there must be transparent disclosure and accountability. A culture of easy forgiveness does nothing to raise the standard of healthcare for patients and rather it creates more opportunity for healthcare workers to make excuses for mistakes, which would only make serious mistakes seem more acceptable, not less.

    What incentive is there to do better if there is no standard of accountability? It’s one thing for a doctor to make a mistake but it is entirely another issue when the mistake is covered up to protect his/herself from accepting consequences for the mistake. Spin has no legitimate place in healthcare. The cover-ups, the denial, the cavalier or convenient excuses are the most offensive aspect of this issue to me. It is unacceptable to lie or “smooth over” the facts to avoid taking responsibility or to shield oneself from blame.

    Why not do something about the sleep deprivation that the doctor in the video speaks about? Why do doctors have to train under such extreme conditions while we as patients are treated like guinea pigs? Why are patients and families expected to accept or contribute to the culture of silence and denial about medical mistakes when made?

    I can forgive a mistake, but I cannot forgive lies or cover-ups that rob people of trust. I agree with Kira’s comments. Admitting a mistake and offering a genuine apology is a much better alternative even if it is painful and has consequences for the offender. Why should the victim suffer for the decisions of others and why should a patient and or their family’s suffering be aggravated by a lack of admission of mistakes? Why should a patient and/or their family’s peace of mind not be as important as the peace of mind of those at the source of the mistake(s)? Why should patients and their families be expected to extend their empathy to errant doctors or nurses when harmed by them? Where is the empathy for the patients and their families?

    Shame has a purpose. It is an inner guide to conscience. Dr. Kwok you say, “…the culture of how we view and approach medical errors must first shift away from the traditional shame-based paradigm. And this can only happen in a safe and protected environment…” The safe and protected environment you speak of should apply first and foremost to vulnerable patients who depend upon it when in the care of a healthcare professional and/or a healthcare facility.

    Patients and their families don’t need to hear those three little words, “Do you remember?” when they or a loved one are harmed or a loved one dies due to medical error, indeed, we can never forget. Blame also has a purpose. It is assigned to those we perceive are responsible for medical errors. Generally, in my opinion, we tend to blame others and judge them more harshly when they try to excuse, deny or cover-up their mistakes instead of admitting to them. Trust between healthcare providers and patients and families cannot happen if we cannot believe what we are told when things go wrong or when the truth is withheld from us. It should not be the decision of the offending healthcare professional to decide if and when disclosure about medical mistakes is appropriate. Admitting mistakes and accepting responsibility for them should not be a healthcare provider’s choice, but it should be their ethical duty to their patients and their patients’ family. Ideally, I would like to think most healthcare providers agree.

    • Jeremy Petch

      Thank you for your comment, Catherine. I agree with a lot of what you say, I want to offer two brief thoughts.

      I think there can be a difference between accountability and punishment. I don’t think the author is suggesting no accountability… I think what he’s saying is that punishment and accountability might not be compatible, because fear of punishment leads to cover-ups, so no one winds up being accountable. If we remove punishment (or save it for when there is intentional wrongdoing, vs. honest errors), I think he’s saying we can have better accountability, but accountability won’t mean jail or lawsuits, it will mean “you made an honest mistake, you are accountable for explaining to the patient and family what happened, apologizing honestly for your mistake, discussing openly and honestly with your colleagues about how the mistake might have been avoided, and accountable among patients and peers for improving in the future.”

      I also think it’s very important to distinguish between intentional wrongdoing and medical errors. I think your analogy to murder isn’t appropriate in the case of errors. I will always support punishment when someone intentionally does something wrong (and that includes covering up mistakes), but the comparison to murder suggests that when mistakes happen, they are somehow intentional. While someone who intended to do harm (like the murderer) won’t change their behaviour if punishment is removed, those people who make mistakes have a better chance of improving in the future if they’re not scared of being punished the same way an intentional wrongdoer is if they make a mistake. That’s my 2 cents, anyway.

      I think it’s a really important discussion and I’m glad to see so many perspectives here. Thanks everyone for your comments.

      • Catherine Richards

        Jeremy, thank you for your response. I see where you are coming from and understand completely that there is a difference between intentional and unintentional errors, but so is there a distinction with a murder that is planned or that just happens in a situation where many elements escalate out of control. I see medical errors in a similar light.

        The point of my analogy is not to offend by comparing healthcare workers who make mistakes to premeditated, calculated and cold-blooded murderers, but to draw a comparison that just as someone who commits murder unwittingly, a healthcare worker’s decision or omission may unwittingly cause the death of an innocent person and in my opinion in both scenarios there must be some sort of accountability and consequence.

        I actually think that a convicted murderer who commited a crime in a moment of passion and has spent time in a prison for the crime is more likely to learn a lesson and turn a new leaf than will a healthcare worker who decides to reject the concerns of family and places an infectious person in a room with an elderly and immune-compromised person which results in the death of the frail senior and for which the healthcare provider receives no penalty. For the record, my examples are not from my experience but used only to illustrate my point.

        I do believe wholeheartedly that healthcare providers feel afraid to face consequences for their mistakes, but from my experience they and their administrators rally together to protect one another and will go to great lengths to discredit the victims of their mistakes and/or their families and that it just wrong. There may be innocuous mistakes that happen daily in healthcare settings by healthcare providers, but until healthcare workers and administrators realize that one small mistake can lead to another and another and by the time all are added up a person may be dead or negatively impacted for life, there will be no detectable change or improvement in the system, and therefore it is vital that all mistakes are accounted for as soon as possible before they multiply and cause great harm.

        In my late mother’s case, I first mentioned small mistakes or oversights such as a lack of supervision and a complete breakdown in communication between shifts among staff about important details I would report about my mother’s health ie her need for increased water, repeated UTIs, lost test results etc. I encountered resistance, very poor attitudes and unwillingness to listen by those caring for my mother as they failed to respond appropriately, document accurately or retain important information about her health. My concerns and criticism which were justified were met with hostility rather than a willingness to help. The controversy only grew over time to include retaliation against me for complaining, even after I had complained to the MOHLTC which seemed more intent on protecting the healthcare workers and the nursing home management and admnistration than my mother. Ultimately, as my complaints were ignored or dismissed and I was painted as a trouble-maker, most unforgiveably, my mother suffered and died, dehydrated.

        To date, though I am still pursuing accountability for my late mother and me, and others who have experienced injustices in the healthcare system, I have received no apology from those involved, no words of heartfelt desire to do better, the kind you suggest as a means of accountability. A lawsuit may be my only remedy but that is because of the utter failure on the parts of those involved to admit responsibility and to offer to do something about it for the benefit of others in the future. Instead the denial and avoidance of responsibility persists. The fear they have about accepting responsibility that may lead to consequences, is what prevents them from helping to heal these type of situations but it also actually makes patients and/or their families feel that lawsuits are their only legitimate avenue to accountability. Until integrity rules without question their judgement and decisions and willingness to admit mistakes, all healthcare workers and administrators will be unfortunately tarnished by the unconscionable actions of some. I believe accountability includes consequences in relationship to the offense and it always includes telling the truth.

        • Jeremy Petch

          I think at the heart of this discussion is a tension between two priorities: justice for past wrongs on one hand, and the desire to reduce future wrongs on the other.

          As all of the comments here make clear, our current system doesn’t seem to be doing either particularly well.

          To me, both priorities are of great importance, but the story of Utah makes me wonder whether we can actually create a system that does both effectively. I hope we can.

          • Catherine Richards

            Jeremy, thanks again for your comments. I think if patients could achieve justice for past wrongs that would invariably inspire a greater desire among those in healthcare to reduce future wrongs. The two concepts to me are not only clearly connected, they cannot be separated.

            If the healthcare culture welcomed the notion of accountability for past and present actions and had a genuine regard for learning from mistakes to prevent them from happening in the future, it would serve to increase patient trust in their healthcare providers and confidence in the healthcare system at large.

            Just healthcare is a worthy goal for all involved. I share your hope!

            Best regards,
            Catherine

    • Catherine Richards

      Christopher, I think your article is brilliant! Thanks for sharing it wit us all!

      • Catherine Richards

        My keyboard is faulty and it’s dropping letters when I type. Correction: Thanks for sharing it with us all!

  6. MARY-LOU PATEY

    I think we need to expose the doctors that are making horrible mistakes. We have many good doctors, but they continue to protect the bad ones. My son was killed on June 12/12 by one very arogant doctor and one other doctor’s misdiagnosis. He was only 25. His life was taken and mine was destroyed. The public is so unaware of how many times these things are happening in our hospitals. Ontario is the only province that the Ombudsmen are not allowed in the hospitals. Nobody is allowed to investigate the hospitals. We need to change this. I am fighting to get justice for my son and have started a website http://www.justiceforjosh.com. All i want is an inquest so this does not happen to anyone else but of course they do not want this because they may be exposed. In my case my son had a lack of proper care right from the beginning to the end.

  7. Bart Windrum

    And where in this examination is the idea of compensation to the harmed patient-families? Once again the conversation is all about providers.

    • MARY-LOU PATEY

      I agree there is no accountability to the patients or families and compensation is so hard to get since the Canadian Medical Protection Association has billions of dollars in reserve and will spend 10 times the amount that the harmed people will spend. Thus most people give up and this is what they want. by the way our tax dollars help to fund the CMPA. Is this fair that we are funding the ones that fight against us.

  8. Joel Selmeier

    Refusing to pay for injuring patients is not punishment. It is an attempt make it so that injuring patients is not more profitable than healing them.

    Policies, habits and routines gravitate toward that which generates revenue. It costs money to prevent infections. It generates money to treat them. So caregivers do not have time to prevent infecting the millions of patients they infect each year because of what that would cost – unless it were arranged for that to cost more, like if they didn’t get paid when they infected patients.

    Unfortunately, refusing to pay only further incentivizes falsifying records and we end up with almost no injuries resulting in refusals of payment.

    But your thoughts about this treat it as though individual, innocent mistakes by well-meaning caregivers were the only problem and doesn’t take into account routines and policies that allow a certain percentage of patients to die or become disabled because it would cost too much to protect them. It is difficult to define those as errors.

    And you thoughts do not take into account just plain bad care, for instance when a doctor has an opening and so treats something he/she really shouldn’t attempt, rather than referring the patient elsewhere, and leaves the patient with a life-altering injury, but accomplishes his/her goal which was to generate revenue in that time slot. Or worse, when the caregiver has an appetite that is not in the patients interest and violates the patients trust and gets paid every time he/she does.

    The mindset in medicine continues to be that everyone means well and tries hard but every once in a while that is not enough. If that really did mean that well and try that hard, the might be enough. But they don’t. And they don’t know that about themselves.

  9. Edmund Kwok

    Thanks everyone for their comments and inputs.

    I have to agree with Jeremy’s earlier reply: there is a clear distinction between honest mistakes (what this article is talking about) where things could’ve been done better, versus medical malpractice (including intentional cover-ups, obvious incompetence, etc.).

    Unintentional medcial errors occur on a daily basis, by well meaning individuals. Ideally, we can examine the reasons for why bad things happen despite good intentions, learn from those mistakes, and try and prevent them from happening to someone else in the future. But the first step in order for this to happen is the recognition of the errors, and the willingness to talk about it.

    Medical malpractice (which some of the commentors are referring to) is a completely different topic.

  10. john hoefen

    when our son was injured it said on the emergency records he needed surgery for his epidral hematoma. Why he didnt get it and why his doctor and nurse lied to us that he didnt have a serious injury is beyond me.Or it could be they lost the window of repair and if they did it now he would have lived but would have been impaired.It seems if a doctor has any characterr he wouldn t lie.he would think of the patient not himself.
    Outright lies and concealment leading to death should be punished severely.

  11. Kira

    I do think there is a huge difference between an honest mistake and malpractice or negligence however you want to define it, but the consequences for patients and their families can be the same. We say we want doctors to be honest, acknowledge mistakes and then try resolve, treat, refer, help the patient. People forget doctor’s, healthcare providers are made up of people just like politicians, lawyers, advertising executives and bankers not everyone in any profession is ethical.

    I think it’s important to figure out when ethics became a disadvantage rather then a quality people look for. I was raised you do the right thing because it’s right, it’s not always the easy but we are a society and culture that values and rewards the most well worn paths, the easiest solution.

    The difference to me is that a doctor takes an oath to first do no harm and everyone is going to fall short at some point but it is how we handle those moments that matter most and speak not just to our profession but the person we are and strive to be. And having worked on discipline and fitness to practice cases I really believe most doctor’s have little to no understanding of the long term harm they can cause by denying or ignoring honest mistakes.

    I don’t know how we change that, but it starts long before medical school.

    • Catherine Richards

      I so agree with you Kira, with one exception: I would like to think that the majority of healthcare providers do have a great understanding of the potential harm they could cause to patients; most do have a conscience and are sensitive to the patient’s predicament, and most would have the integrity to admit mistakes and to accept the consequences for them. If I were to believe that most healthcare providers did not have these qualities then I think I would never be able to trust any of them and in my history I have met, thankfully, many more good examples of healthcare providers than not. Having said that though, when one has a very tragic experience in the healthcare system, a system that seems to protect its own at all costs, it is understandable how patients become disillusioned with the healthcare system that appears hesitant to foster a culture of genuine accountability.

      The healthcare community needs to change its attitude, I believe, by not only encouraging but expecting those who make mistakes to own up to them and to never cover them up, and to accept responsibility and consequences where appropriate, because such behavior unchecked or denied only deepens the systemic problems in healthcare and adds more misery to those patients who suffer because of them, and that’s a real shame!

      • Joel Selmeier

        Catherine, I don’t know what it would take to get providers to tune into this, but when a patient has an iatrogenic injury and is trying to get treatment, what is learned is that no healthcare providers have a conscience and none are sensitive to the patient’s predicament. Honestly, none.

        You probably imagine you that would be different, but injured patients are who call me, and if you didn’t do what all providers do, you would be the first who didn’t. They have to be there for the next patient. They cannot let one patient ruin their careers. They wouldn’t want colleagues to give credence to the frivolous claims of a crank patient who could ruin their own career and so they won’t diagnose injuries that could hurt someone else’s, let alone treat them. It is not uncommon for them to warn each other about such “crank” patients. It is not uncommon for them to write pejorative things in the charts. It would be extremely unusual for any of them to make any record at all of what the patient says about how the injuries were incurred.

        Injured patients spend years going from doctor to doctor to doctor trying to find anyone who will help them without anyone even doing the tests that would diagnose the injuries, let alone treat them. And all of those doctors believe they are “one of the good ones.” I know because I have talked to enough of them.

        I have talked to doctors who have quietly avoided caring for such a patient and have no awareness of having done that, which is what is normal. I talked to a doctor while he was actively engaged in calling other doctors to warn them not to diagnose the injuries of a patient. I asked him if there was any such thing as blacklisting in medicine. He snorted and said that after his decades in the practice he would know about it if there was. He had no awareness that what he was doing was blacklisting a patient. And no thought at all about whether the patient might have real injuries incurred at the hands of another caregiver.

        This might be the biggest problem in medicine – comfortable ignorance of that which is not comfortable to understand. Agnotology is one word for it. Forgive the comparison, but did you ever wonder how middle class Nazis in Germany, running businesses and raising children, could see Jewish neighbors disappear once in a while and never become aware of what was going on? How can providers in contemporary America as blithely believe that most providers are sensitive to the patient’s predicament? I have never met one who understands that the scenario that I described above is the predicament of patients when providers injure them either accidentally or on purpose. That and worse happens to them. But every provider I’ve ever communicated with believes him/herself to be sensitive to the patient’s predicament. Even a nurse who didn’t report the serial killer working on her ward believes that. I know because I communicated with her.

        If a nurse doesn’t sterilize well enough and a patient dies as a result six months later, does anyone tell the nurse? Does anyone even keep track to see if one specific nurse turns out to have been involved in the care of every infection fatality a hospital has? No one wants to know so no one does. Everyone can comfortably believe they are sensitive to the patient’s predicament and have consciences.

        If you think I’m describing outliers, and one in a million occurrences, that is agnotology.

        I’d be happy to communicate with you about it further privately if you want to contact me through my website: http://www.patient-safety.com

        Sorry for the length of this post.

        • Catherine Richards

          Thanks again for your comments, Joel, but I must say that you lose me when you say there are none in the healthcare system that are sensitive to the patient’s predicament. I honestly cannot buy into your argument as from my own experience I know this is untrue, as it is untrue for many I believe.

          Yes, I would like to think that even in the presence of systemic and indisputable issues in healthcare, and within a culture that resists accountability rather than readily welcomes it, there are real people who make up that system and many if not most (I think most) do have honour, conscience and integrity. If I were to think as you do, I would not bother even trying to change things as we would all be doomed as we would certainly be outranked and outnumbered.

          I cannot think of any debate that I would argue that an entire group of people think or act one particular way.

          I am literally on my way out, but I will take the time this week to respond further.

          • Joel Selmeier

            I’ll look forward to discussing it with you further.

            Is there any chance we could do it on the phone? It would save so much time.

            In case it helps to clarify what I’m saying, the way to judge a system is by how it handles its worst moments. Anyone can be compassionate and sensitive to someone who arrives sick and needs help. It is more trying with people with difficult personalities. And more difficult when it’s been a long day and others need help and there are not enough other people and resources, etc.

            But the real test is the darkest moments. Will they stick their necks out to report colleagues who operate while inebriated? Will they diagnose the injuries of someone abused by a caregiver. Every single one I’ve met says they would. But when faced with it, they don’t. I sit on the other side of that wall listening to the victims.

            Here’s my phone: 513-348-4744

          • Joel Selmeier

            As you think of your response, consider the fact that you already have done what I have said all caregivers do. You have disbelieved the experience of patients. Try to find a caregiver in this discussion who hasn’t concluded that I must be a crank probably not worth listening to when I repeated what happens to patients trying to get iatrogenic injuries treated. You said that from your own experience you know it is untrue. Would it not be more accurate to say that your Perception of your experience allows you to believe it is untrue?

            In the 1950’s the psychologist Solomon Asch did a series of laboratory experiments that showed that three out of four people will give an incorrect answer to a simple question after overhearing others give that incorrect answer. These were questions that children could answer correctly if left alone to come up with the answers. But when intelligent adults overhear other adults give wrong answers, they give the same wrong answers. More recent research (lead by Dr. Gregory Berns, a psychiatrist and neuroscientist at Emory University in Atlanta) using MRI’s shows that they are not lying. They actually see solid, physical things differently based on what others have said.

            Seeing can be believing what the group says to believe. And the group in medicine believes what you said above, that from their experience they know the experience of injured patients is untrue.

            That is what I said all caregivers do. I said you would do it too. And you did. You disbelieve what the report of what happens to patients with iatrogenic injuries.

            How can caregivers be sensitive to the predicament of patients when they don’t believe that the predicament is true?

            An objective third party could have a very different perception of what your experience proves. Caregivers cite the opinions of other caregivers, but other caregivers are not objective third parties. They are from the same group, a group that disbelieves patients with iatrogenic injuries.

            It is rare for me to try to make this case with a caregiver. But since it is one of the fundamental problems in medicine, once in a while I poke at it to try to increase my understanding of the culture and the thought processes in medicine that enable it to practice its flavor of agnotology.

            If you ever decide to call me, perhaps we can talk about that.

          • Catherine Richards

            I don’t know if it is such a wise idea to publish your phone number on this site, Joel, but I just wanted to let you know I won’t be calling you. While I do agree with some or your thoughts, I cannot agree with them all. I cannot relate to black and white, all or nothing thinking. I hope you will agree that perhaps it is best that on this subject we agree to agree on some things and to accept that we disagree on others.

            All the best,
            Catherine

          • Joel Selmeier

            I didn’t think you would call. But from time to time I give a caregiver the opportunity to be the one who introduces a shade of gray.

            7 or 8 years ago I tried the equivalent of a parlor trick in which I asked doctors a question and as they said their answers I held up a piece of paper on which I’d already written the exact answer they were repeating to me, word for word. It was an answer easily shown to be ignorant and yet fundamental to the safety of patients. I was seeing if it might be possible to get somewhere by making a point about the group-think in medicine, but wasn’t a kind approach it, and it didn’t get anywhere.

            I’ve tried charm and subtlety and the opposites of both of those. I’ve tried facts and peer reviewed journal articles and sales techniques and argument. But it is like landing in Baghdad and trying to persuade militant Islamic priests that what they think Allah wants might be more a phenomenon of their culture than of anything actually occurring in the spirit world.

            I hear caregivers explain things like what they believe patients want and it has nothing to do with what actually is occurring in the patient world. So many of the things believed in medicine are the product of the culture there and not anything evidential. Like when they say that they and the caregivers they know are sympathetic to the predicament of patients, when they don’t even know what happens to the patients they injure. That would be the first thing they would have to know for that claim to be legitimate.

            I care because the gap between truth and belief eventually is fatal. And the unacceptably high rate of unnecessary fatalities in medicine is something I care about.

            Thanks to the powers that be for not kicking me out of the discussion for presenting the patients’ perspective. I’ll be quieter in the future.

  12. Joel Selmeier

    Safe and protective environments in other fields lead to more errors (and sins). If the end goal is to make medicine safer, and not just richer in reporting, this probably is the wrong path to follow. Especially when you consider how unlikely it is to increase honest reporting anyway.

    Discussions of this issue invariably assume that caregivers are not like other humans and so do not interpret the evidence of their senses in self-serving ways. The assumption is the caregivers are lucid and objective, although studies suggest they are not. Like the HHS study that found that only 2% of adverse events get reported accurately. I’ve yet to meet anyone in medicine who believes it, but I’ve spoken to numerous injured patients who do.

    Ask injured patients what appeared in the record about their injuries. Nothing. No matter how safe and protected the environment, and no matter what they are taught, people rarely file bad reports on themselves. Only rarely do they even recognize when they should. Somehow no one in medicine will entertain the idea that caregivers might not interpret the evidence of their senses in the same way that objective third parties would, and so what gets in the record, even in an operating room full of people with the ability to report, still has too much in common with novels written to make the authors heroes.

    Being safe and protected and well-taught does not change human nature.

    • Catherine Richards

      I agree with your comments, Joel and I know from the many issues I had when I was my late mother’s Power of Attorney that one’s health record is also very vulnerable to potential abuse by medical and administrative staff who do not always report truthfully about mistakes and sometimes embellish or justify situations to their own advantage to cover up for their mistakes or mistakes of colleagues.

      The health record is in my opinion a powerful legal document that depends upon the absolute integrity of all those making notes in it. One’s health record is in reality, in my view, a highly subjective account of the what happens to a patient and of course, it almost always protects the medical and healthcare administrative staff from consequences for mistakes because the details are either missing, misinterpreted, or justified. I don’t believe that there is always an ulterior motive for not accurately capturing and reporting on one’s mistakes, but if an ulterior motive exists, there is no more protected a place than the health record to exploit it. Rarely do patients even see what is written in their health records, and health records are rarely successfully challenged, although one can in Ontario ask that a patient or Substitute Decision Maker’s notes be added to the record to dispute or clarify the healthcare provider’s account from their own perspective.

      Trust is so important between patient and healthcare provider because when it comes right down to it, the patient has so little control over what is said or written about them and the situations pertaining to their health. A patient’s account and a medical and/or administrative staff’s account of what constitutes a mistake is often at odds and the medical staff is generally and conveniently perceived to have more credibility than the patient. In an emergency situation, a patient is more vulnerable than ever as they have no time and little choice but to accept the care of those assigned to them and therefore trust cannot be truly established. So much in healthcare depends upon the patient being able to trust the integrity of their healthcare providers. Patients are at the mercy of the healthcare provider, not the other way around, and therefore the healthcare culture needs to accept the responsibility for this inherent imbalance of power and respect the great power they hold over the lives of others, in my opinion.

  13. Kati Debelic

    There are medical errors, and there is medical neglect. Patients with myalgic encephalomyelitis aka chronic fatigue syndrome (me/cfs) have been neglected for decades. There are 411 500 of us in Canada (Community health Survey 2010), a staggering 205% more than in 2001. Patients’ functionality is anywhere from able to walk 1-2block to being housebound and bedbound. We die averge 20 years earlier than average from heart events, cancer and suicide. There are no medical speciality currently caring forthis disease and rheumatologists are making it clear it is not their department. UK psychiatrists spread their rpropaganda that CBT is the only treatment, but then they ignore all biomedical research that has been done, including Valcyte, Ampligen and Rituximab clinical trial.

    The canadian government is funding 0$ for research for 411 500 of us. That is neglect too.

    Medical neglect has got to be punished.

  14. Gerald I. Goldlist, MD

    The topic was “Should We Be Punishing Medical Errors” and there seem to have been many tangential comments. We should be rehabilitating medical errors to prevent them from reoccurring. If I prescribe a drug and the patient has a reaction to it, is that an error? I think not. But the patient might think of it as an error. If I treat a non-specific corneal ulcer with antibiotics and it turns out to be Herpes,is the fact that I did not use an anti-viral an error? I was playing the odds and not sure. I had to make a decision right away and by the law of averages there would have to be a certain percentage of errors. If I judged an unreliable visual field defect (because of the patient’s ability to do the test) to be normal and the patient later lost vision, is that an error or an educated guess?

    If a doctor makes an error because he lacks some esoteric knowledge is that an error? I suppose so. Should he be punished or rehabilitated by teaching him the information or a better way to keep up or examine a patient or whatever needs to be done?

    We rehabilitate some criminals instead of punishing them. The criminals knew what they were doing was wrong. Doctors and nurses do not purposefully do the wrong thing. How would punishment make them want to do better when they already want to do the best for the patient?

    Not punishment but rehabilitation.

  15. Joel Selmeier

    The biggest problem I have with your argument is an assumption that is so cherished in medicine that it really isn’t possible to get caregivers to consider the possibility of its not being true. It’s the idea that caregivers want only what is best for the patient and nothing else, as though personal interests never clouded judgment.

    Caregivers in general believe so completely in the infallibility of their own motivations that they are shocked when data shows that personal gain, like financial incentives, determines the direction of the care they dispensed more than what is best for patients.

    Not paying for bad outcomes is an attempt to make incentives in medicine less perverse. When care is profitable whether or not it is beneficial, and when caregivers make even more money when it is not beneficial because the problem still needs treatment, and when, beyond that, they can make even more when the care makes the patient worse, there is a perverse incentive to find reasons to believe in treatments rather than to gain knowledge, that might seem esoteric, in order to be sure the care is the best thing for patients.

    For perverse incentives not to cause problems, caregivers would have to be saints. Only saints could be objective enough to be aware of when their own interests are clouding their judgment.

    I’m not a fan of bureaucrats trying to massage incentives in an attempt to get caregivers to take better care of patients. I think it further increases the extent to which caregivers focus on how to get paid, rather than focusing on the outcomes they produce for patients. Like this discussion. And to produce records that result in only 17 instances in a whole state in which caregivers did not get paid. It already was the case that almost no adverse events were getting reported. Now only 17 in a whole state? What good did it do to not pay?

    Still, I don’t see this as punishment as much as an attempt to make incentives less perverse.

  16. Gerald I. Goldlist, MD

    Contrary to what most of the comments here imply, the first thing that I learned in university was that it was impossible to know everything.

  17. Joel Selmeier

    Non-punitive systems are not suddenly rich in reporting. They are rich in reporting the 2% of adverse events that get reported. To the subjective mindset of the caregiver that appears to be all there is to report. They declare the world to be much better with many problems solved as we trudge on with only 2% of adverse events being recognized as such by caregivers. They don’t believe the statistics about how little gets reported. They don’t believe the experiences of injured patients who found nothing in the record about what happened. And they cannot be persuaded that caregivers might not be objective and selfless enough for their perceptions to be relied upon in these matters. In other fields there is awareness of how their perceptions are skewed by self-interest. Medicine is resolutely in denial about it.

    The remaining 98% of the reporting that needs to be done is going to have to come from someone other than caregivers because caregivers have an unshakable belief that their perceptions are objective and unswayed by personal considerations or the group-think in medicine. Even a discussion about this cannot be gotten going. So a solution is going to have to be brought about without their involvement . They remain in denial of this even being an issue, let alone possibly the most fundamental problem in healthcare.

  18. Matthew Law

    Of course each instance needs to be evaluated on a case-by-case basis. There are obviously varying degrees of “mistakes” and “errors.” Most physicians are so terrified of malpractice claims (and increasing the increasing cost of malpractice insurance), that they do there best to provide the best treatment that they are capable of. Fear of punishment is unlikely to decrease treatment and diagnostic errors. If anything, it could very well make it worse.

  19. L Gibson

    I appreciate that medical personnel are human and that punishing can lead to hiding issues rather than exploring their causes and resolving them. Recently a close relative died when a physician prescribed two medications simultaneously that all literature clearly states are fatal in combination. In this case i believe the physician should be held accountable. The hospital where this occurred has swept the issue under the rug acting as if there was no issue at all. How can patients trust Dr. competence when fatal information is readily available and ignored with tragic consequences?

  20. irene Chain kalinowski Author, lecturer

    Hats off to you for this message. I see so many good and experienced health professionals suffer depression feel suicidal after years of providing care that is exceptional. The Blame name scenario and that of punishiment drives the best out of practice and the system changes to provide fear and discord in the health systems. the systems should encourage learning growth, encouragement and it needs to praise what is good and work to improve what is at fault. it is not just the health professional that is to blame. it is often the entire system that fails the professional.

  21. Domonic Flanders

    I’m not going to be fancy with this comment, or have long paragraphs explaining myself I just wanted to say that my mother is a victim of doctor error, and i understand that some people are mad at there doctors. But i’m not. I cant be mad a a person who dose so much for us. My family has lots of cancer problems and most of the problems were resolved for the time being. I am so greatfull that the doctors of New Hampshire are as good as a person as they are a doctor.

  22. Sharon

    Punishment for medical errors? Yes, yes, yes, a thousand times YES!

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