Originally published on November 22, 2016 at www.lmshealthpro.com.
By Anita Haridat, Ph. D
From all of my professional experiences within hospitals in
New York, it seems that an organization’s “reason for being” is to provide the
best possible health care when needed. Unfortunately, I’ve also learned that
problems arise when the hospital’s mission is “to generate a profit”, to
“advance science”, or any other mission that might be at odds with providing
the best possible care in the short term. The same applies to individual
clinicians and clinical teams within the hospital.
Then, I thought about a common patient safety movement
commandment “errors represent system problems.” In a sense, it also represents
the fact that “thou shall not blame.” Like most complicated issues in
life, the truth lies somewhere between these polar views. Overall, the “no
blame” view is right – most errors are committed
by good, hardworking doctors and nurses, and finger-pointing simply distracts
us from the systems fixes that can prevent the next fallible human being from
killing someone.
Yet, taken to extremes, the “no blame argument” has always
struck me slightly naïve. Let’s look at a case from just this year in April. A
24 year old received a routine wisdom teeth removal and woke up coughing during
the procedure. He was given the powerful anesthetic propofol, but his condition
quickly deteriorated and he was transferred to a hospital, where he died three
days later. According to the patient care report, the paramedics said that the
patient woke up during the procedure, started coughing and was given propofol.
When the patient stopped breathing, CPR was started and the paramedics were
called.
After they arrived, the paramedics found two pieces of
surgical gauze in the patient’s airway as they tried to intubate him. How can
such a careless mistake lead to the death of an innocent man?
What’s most shocking is the healthy 24-year-old goes in for
an operation as routine as having his wisdom teeth removed and dies in the
process. So the question remains- when is a medical error a crime?
According to dozens of enterprises for risk management, there
are three kinds of behaviors that can lead to errors:
Human error – inadvertently facilitating a process
other than what should have been done; a slip, lapse, or mistake.
At-risk behavior – a behavior or process that may
increase risk or recognition that the behavior is mistakenly justified.
Reckless behavior – a choice that is made to disregard
unjustifiable risk in a conscious manner.
Were the surgeons involved with the case criminally
prosecuted? I doubt it. There was legitimate remorse and regret towards the
family. However, I will go so far as to say that there should have been
counseling, suspension or arguably firing done. The case is still open- just
like so many other medical error cases and unfortunately, my main question
still stands. What are your thoughts?
Leading Management Solutions helps medical
practice leaders identify ways to improve operations to increase revenue,
employee engagement, and patient satisfaction. Learn more about us at www.lmshealthpro.com.
About the Author:
Anita Haridat has her Ph.D in healthcare/business
administration and her master’s degree in clinical nutrition. She has
several publications in sources such as EGO Magazine, Natural Awakenings
Magazine, Syosset Patch, Our USA Magazine and many more. Her passion for
health and wellness has created multiple stepping stones for paving the
way of creating a positive well being. Her first book can be found here:
