I encountered a moment of truth while creating an online interactive class regarding Risk Management in healthcare recently.
I had presented information about the importance to integrate risk management thinking into everyone’s job; in essence to critically question, “what can go wrong” to proactively protect the patient from harm. To further support the necessity for risk management, I provided recent medical error data of completely overwhelming patient harm and death numbers.
That is when I asked myself again, as I have done so many times before – how did the industry I love; one that is full of dedicated, good, altruistic people, get so far off the tracks? Where did we lose our way? When did anything else become more important than the patient before us? What derailed our priorities and confused the picture and how it is we are working so hard and impacting the overall health of Americans so little. And why, why, why did I not know?? Of course I have experienced the problems, the barriers, and the disconnects – but I have no one good answer as to the overall cause.
So, I did a Google search, thinking surely some greater mind must have an answer. I asked why is healthcare so bad, why does healthcare kill so many people, why do so many die from healthcare in America, why aren’t we outraged about healthcare?
Here is what I found:
Anti “Obama care” articles from 2007.
Why do pharmaceutical drugs injure and kill so many people from 2004.
A gaggle of public responses with varied answers regarding bad healthcare in 2006.
Where is the outrage regarding children dying in childcare settings in Missouri from 2012.
Hundreds of thousands of patients are dying BECAUSE OF healthcare – and there is no single reason to be found! Not even the greatest repository of human knowledge in all of human history could answer the question.
Medical error is not intentional – they are mistakes – and we in healthcare, seem to excel at producing them. But of course there is plenty of contributing factors – records that don’t interface, medications that look alike, poor handwriting, worker fatigue, alarm fatigue, being rushed to do more with less, interruptions, human error, payer requirements, the list is endless.
Consequently, there are also ample knee-jerk reactions to affix to each symptom of a much larger malady – National Patient Safety Goals, performance improvement projects, core measures, root cause analysis, failure modes analysis, initiatives, campaigns – and still patient deaths occur BECAUSE OF healthcare. There is no smoking gun and no troop of vigilante assassins. Patients continue to die from a multitude of innocent errors and we keep applying shallow fixes atop an enormous epidemic of failure.
There may not be a single solution, but three truths come to mind:
1. The current approach is NOT working. Another regulation is not going to produce miraculous results in patient survival at the hands of those juggling numerous healthcare mandates today.
2. The practice of healthcare over the past two decades has expanded in complexity beyond the capacity of the average human mind to comprehend, safely apply, and readily adapt to the onslaught of its associated change.
3. The diversity and prevalence of lethal medical error indicates the cause is not only systemic and incessantly insidious, it is pandemic in nature. Platitudes are not going to tame this beast. It is stealthy and ubiquitous with tentacles that reach deep into the soul of healthcare behavior.
One thing however, is apparent. The future of all humanity is our patient – and safe healthcare requires a complimentary structure that works for, with, and beside us imperfect mortals – instead of us working to feed a ravenous and ineffective system.