Mistakes come in all sizes and flavors. At one extreme, they are dumb and harmless and can be simply erased, just like the wrong answer to a math problem. Remember all those little eraser droppings you brushed and blew off your notebook paper? No harm done. Mistakes easily fixed. Learning happened. Life goes on.
At the other extreme, mistakes can be life threatening, maiming or even cause death. An alcohol-induced car crash, abuse of a loved one, friendly fire, the slip of a surgeon’s knife, the doctor’s prescription for the wrong drug, any of a number of catastrophic bad decisions. They aren’t just mistakes, they are lapses in judgement or skill that may harm or kill a human being. These are the cases where simply learning from mistakes isn’t enough. There must be acknowledgment, and perhaps punishment.
Should any of us be held to higher standards when it comes to making mistakes? Yes, of course. Those who choose to be in positions where their judgements and choices create ramifications for the lives and well-being of others. Presidents of countries and corporations, judges, militaries — and health care professionals. Perhaps others, too.
I raise this point because my google news alerts popped an interesting link int0 my inbox the other day. It’s an article by two Mayo Clinic physicians, a PhD, and a fourth author, called Journal Reporting of Medical Errors: The Wisdom of Solomon, the Bravery of Achilles and the Foolishness of Pan. Only the abstract of the entire article is available — so here’s my disclaimer — either the title and abstract are a bad representation of the article — OR — here are some enlightened doctors with a good start on an enlightened idea, making that idea public.
Drs. Murphy, McEvoy and PhD Oshiro assert that there are good reasons for making medical errors public which benefit both patients and doctors. They state, “The veil of secrecy that surrounds medical errors deprives health-care practitioners of knowledge that may help prevent similar adverse outcomes for patients in the future.”
Their assertion is that just telling an individual patient that a mistake has been made isn’t enough (yes — OK — they may think that happens, but I’d be very surprised if doctors own up to mistakes even half the time). They promote the idea that sharing those errors with colleagues rarely happens now, but sharing those kinds of errors in medical journals would help other doctors avoid the same mistakes. They even go so far as to say there is a way of doing it confidentially while still improving patient safety.
I give them big “woo hoos!” for a good start. But that’s what it is — just a good start.
I like their idea except the veil of secrecy aspect — pardon me — confidentiality.
I wrote last week about the online publication of malpractice suits against doctors (Malpractice Goes Online). I do believe that public disclosure and easy access to the information is important.
As a patient, I should be able to make choices based on a doctor’s ability to do the job and do it right. If all mistakes become public, then the real cream of physicians would rise to the top. Yes — everyone makes mistakes — but public disclosure would cause doctors to be more diligent in making the right choices. They would likely make fewer mistakes.
With full public disclosure, I think we would find that very few doctors were mistake-less. And honestly — if a doctor has already made a mistake, I know that doctor is very likely going to be much more diligent than s/he was before the mistake was made. Like flying with an airline that has just lost one of its planes and the souls on board — their procedures become instantly and completely buttoned up to prevent more problems. They become the safest airline to fly, especially shortly after the problem. Learning the hard way is an effective teacher.
Why should doctor’s records and abilities be public when other professions don’t have the same required level of error reporting? Because — doctors need to be held to that higher standard. Just like presidents and judges, and anyone else who holds a person’s life in his/her hands. The choices they make can be life or death — and as the patient-consumer, it should be my perogative to be able to educate myself on his/her track record.
Will it ever happen? I suggest that if ever, it’s a long way off. In too many cases, (actually — the majority of cases, in my humble opinion) when it comes to dealing with doctors, the question is more about ego getting in the way, and less about what can help patients. God forbid an ego be bruised to help a patient.
In the meantime, we sharp patients will have to stay ever diligent. We’re choosing doctors with at least one arm tied behind our backs. Don’t expect that to change anytime soon.
We have to remember just who is being protected — and it isn’t patients.
However — kudos to Murphy, McEvoy, Oshiro and Stee for a good start.
But bigger kudos to those who are willing to set aside ego, and remove the veil of secrecy part, too. I hope I live to see the day.
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