Another aspect of the career shift has been the risk of becoming a "glass half-empty" kind of girl, a perpetual naysayer who tells earnest, well-intended, and increasingly cash-strapped healthcare professionals, "Really folks, this is simply not enough. Have you forgotten that medical errors are the 8th leading cause of death in the U.S?” Last week, Oprah helped me out, hosting the Quaids and reminding us that "every year in the United States, more people die from medical mistakes than from breast cancer, AIDS and car accidents…combined. It's a major, major health issue that will touch almost every single American at one point in our lives."
I’m not a person who sees the glass is half-empty, nor am I an apologist. So I’ll share here what’s helping me to reconcile the irrefutable mismatch between intention and outcome that is healthcare today.
First, it may be helpful to simply acknowledge that errors are very common in healthcare. So common, in fact, that the Agency for Healthcare Quality and Research has endorsed a taxonomy to describe and categorize them. While this may be shocking at first glance, it’s actually good news: Using a specific nomenclature to describe events and categorize them is an epidemiologic approach to problem solving. Taxonomies are used in the study of other vexing problems (like breast cancer, AIDS, and car accidents). So, it’s reasonable to expect that similar processes would be used to diminish the incidence of our problem: medical errors.
While the charge “First, do no harm,” may resonate with many clinicians, this is a goal statement, not a process map. “Just Do It!” just doesn’t, well, do it when it comes to solving significant threats to health.
(In case you can't read the label--something that's difficult to do even in here in my kitchen--the little-bitty font just above the green leaves says, "Hand Soap.")
Two distinct products that share similar packaging, similar color, and similar placement: an error-prone set-up in the community. And an error-prone set-up at work.
This is not to say that I think the consequences of mixing up products in a community setting and the consequences of mixing up products (particularly medications or cleaning agents) while on-the-job are equivalent. In fact, it’s precisely because the risk of harm is so much greater when error occurs in a healthcare setting that processes on-the-job need to be far more robust than what we typically use at home.
I hope you’ll come back as this discussion evolves! (Feel free to use the comment section to share your thoughts with me and with each other.) And in the meantime, I hope you'll stay safe!
Next time: LASA: It’s not just another bad abbreviation.