How do you go about effectively measuring a problem? Is this scenario the answer – or not?
From an article in the New York Times dated this September and titled – New System for Patients to Report Medical Mistakes – the government wants consumers to report medical and unsafe practices by doctors, hospitals, pharmacists and others who provide treatment. Currently there is no one centralized mechanism for consumers to report information about patient safety events.
Federal officials say that medical mistakes often go unreported, and that patients have potentially useful information that could expose reasons for drug mix-ups, surgery on the wrong body part, radiation overdoses and other problems that cause injuries, infections and tens of thousands of deaths each year.
If the pilot project is cleared by the White House, health officials hope to start collecting information in May. Questionnaires will be available at kiosks in hospitals and doctors’offices. Fliers describing the project would be given out at pharmacies and mailed to patients’ homes with the explanation of benefits sent to them by their insurance company.
A draft questionnaire asks patients : “Have you recently experienced a medical mistake? Tell us the name and address of the doctor, nurse or other health care provider involved in the mistake.” And it asks patients for permission to share the reports with health care providers “so they can learn about what went wrong and improve safety.” And it urges patients to contact a new “consumer reporting system for patient safety.” The government says it will use information submitted by patients to make health care safer.
The questionnaire asks why the mistake happened and lists possible reasons – such as:
“A doctor, nurse or other health care provider did not communicate well with the patient or the patient’s family.”
“A health care provider didn’t respect the patient’s race, language or culture.”
“A health care provider didn’t seem to care about the patient.”
“A health care provider was too busy.”
“A health care provider didn’t spend enough time with the patient.”
I don’t know – is it just me – or do those questions sound a bit off target? (See video – Who Am I?) Does a harmed patient really think that a doctor operated on the wrong side because he or she didn’t respect my culture or just didn’t seem to care about me? I’m not sure how well this will actually work or how many trained people it will take to plow through and decipher the no doubt thousands and thousands of questionnaires – let alone the cost.
I’ll be the first to agree that we need a central clearing house where patients, nurses, doctors and others can safely and openly share their experiences, not with the intent to point fingers but as a way to learn from mistakes – to create solutions with a bottom line that something will be done about it. The system needs to learn from its errors, not cover them up or skew them with questions designed to elicit targeted answers.
I wonder – can hospitals borrow safety practices from other industries? I’m told that Toyota has a policy of encouraging everyone on the shop floor to stop the assembly line if and when they spot small problems before they have a chance to become big ones. And that is what we should feel safe to do – not just as a patient but including the patient’s family, nurses and doctors – to interrupt the action and declare a patient-safety alert when anything raises an eyebrow. Or can we create the medical version of the Transportation Safety Board, the agency that probes air crashes. Or a version of the FAA’s Aviation Safety Action Program, that encourages pilots and other industry workers to confidentially report lapses that might cost lives.
The healthcare industry has this bizarre code of silence. Doctor’s don’t call out known and repeated offending doctors and nurses are afraid to lose their jobs should they speak up or even question anything dictated by a superior. I recently heard of a nurse who knew that a 13 inch aluminum retractor was left in a patient during surgery but didn’t say anything until months later when her conscious got the better of her and she anonymously contacted the patient directly with the information.
Healthcare is an entire industry built around a passive customer who does not think he or she has the right to question anything. Well guess what folks – those days are over. There’s an answer to this horrible lack of patient safety. I’m just not convinced that we can’t find a better way to measure.