March 18,
2005
Original
archived
copy
in the Internet Archive
ERRORS OCCUR IN ANY PROFESSION
Medical Errors,
Human Error and Cultural Environments
By
Robert
Reed
On February 17,
2005, Mort Kondracke published his column, titled "Combating Medical
Lawsuits and Errors" on Rollcall.com. It was a good writeup and
brought out some good points on cause and effect, as well as
highlighting some of the things that hinder a full blown "moon shot"
fix for the issue. In fact, the article ties in the GOP business
tort reform agenda with medical malpractice lawsuits and one of the
major causes of malpractice suits which is medical error.
Kondracke
highlights a sobering fact in a 1999 National Academy of Science
Institute of Medicine study that reports that 44 thousand to ninety
eight thousand Americans died every year because of preventable medial
errors. Can you imagine the outcry if the airline industry had a
similar death statistic attibuted to pilot or human error? It
would kill the industry flat out.
I had a small
exposure to the medical world as an EMT in the early seventies when the
EMT program was just getting underway. I drove and crewed for a
private ambulance company in several densly populated Southern
California Orange County cities and became familiar with emergency room
practices over the time I worked in that profession. I also did a
15 year stint in aviation maintenance, and 8 of them were spent as an
aircraft accident investigator for an aerospace turbine powerplant
manufacturer. I interfaced with many pilots, and being a private
pilot myself, many of them became friends.
The upshot of
all of this is my perception of the stark differences in cultures of
the medical world versus the aviation world and their treatment of
human error. In the aviation world, there is an almost religious
awareness of the fallible nature of people, and a good safety-concious
aviation employer will put safety issues and practices above all
others. It's a culture that encourages communication of problems
and weaknesses, to get it out in the open, and to employ mechanisms to
overcome human behavioural factors that lead to mistakes.
As an EMT in the
early seventies, my observations of practices and attitudes are
undoubtedly outdated, but at that time the cultural differences were
still wide between the two worlds. I felt that those medical
personnell who were more highly qualified than I was, namely the
registered nurses and the medical doctors, carried an attitude that was
not like the attitudes of the professional aviation people I knew and
worked with. Their routines were not puncuated by procedure and
checklists, with fail safe mechanisms for patient files and double
checking by associates. Just last week I was given the wrong
prescription papers meant for another patient, and if I hadn't returned
to the medical office for a different reason, the mistake would not
have been uncovered.
There were
exceptions, but the differences in culture were obvious. A flight
crew preparing an airliner or a large corporate aircraft for a flight
is a choreography of procedural checks and industry approved checklists
that should be seen in it's entirety by the lay public. I think
it would improve their perception of the act of flying commercial
airliners. That is a small cross section of the aviation system
as a larger picture. You have the air traffic control system, the
aircraft maintenance system, the aviation weather system among other
systems, all getting training in human factors and human error
scenarious. The systematic approach to preventing human errors in
aviation promotes a culture in a financially healthy aviation company
because the practitioners know that you can stop an accident by
removing any one link in a chain of errors that could lead to that
accident.
In the last two
weeks where I work, one manufacturing error of a machined hole off by
one thousanth of an inch will cost about 4 thousand dollars to rectify
due to consequential damages after the part came off it's shaft.
Another oversight error by an employee cost the company about 1
thousand dollars. A third mistake by me, an oversight error, cost
about one hundred dollars of lost shop time revenue. In our line
of work, a single bolt misplaced or omitted can cost many thousands to
repair and more down time for the customer.
Kondracke's
article is a reminder that the cost of errors is great no matter what
industry you are in, and it also reminds us that errors feed the
industry of litigation. Does the future paint a picture of a world
where they finally get a good grip on the problem of mistakes and
errors and can deal with it more effectively? It's a future I
would like to live in.
(Robert Reed is a contributing columnist for the Eureka Reporter.
Opinions expressed in columns are not necessarily those of The Eureka
Reporter.)
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