A SURGICAL SURPRISE WHEN IT WAS LEAST ANTICIPATED
Medical mistakes are common. Research suggests that about 70,000 patients a year experience preventable, serious injury as a result of treatments. A landmark study published a decade ago estimated that as many as 23,000 Canadian adults die annually because of preventable “adverse events” in acute-care hospitals alone. The rate of errors may be even higher […] Read More
HALF OF ALL SURGERIES INVOLVE MEDICATION ERRORS: John Tozzi
About half of all surgeries involve some kind of medication error or unintended drug side effects, if a new study done at one of America’s most prestigious academic medical centers is any indication. The rate, calculated by researchers from the anesthesiology department at Massachusetts General Hospital who observed 277 procedures there, is startlingly high compared with […] Read More
COGNITIVE BIAS IN DIAGNOSIS:
Cognitive bias is a way of thinking that influences reasoning and decision making, sometimes resulting in inaccurate judgments. Cognitive biases (distortions of thinking) and affective biases (intrusion of the physician’s feelings) may interfere significantly with reaching a correct diagnosis. In recent years, many cognitive psychologists and physicians have studied diagnostic reasoning and decision making. What […] Read More
EXPERIENCE COUNTS
A COMPLEX CASE STUDY: An 81 year old female presented with a six month history of abdominal pain, vomiting, lethargy, depression and a 30 pound weight loss. She developed abdominal pain with vomiting each time that she ate food. PAST INVESTIGATIONS: All prior investigations including upper and lower endoscopy, CT abdomen and ultrasounds were normal. […] Read More
BEDSIDE PATIENT ADVOCACY HAS ARRIVED
With an aging population, seeing a loved one admitted to hospital can be a frightening and overwhelming experience. Hospitals are sterile environments. Doctors do not oversee anyone patient. There is a lack of continuity of care. Medical mistakes are common place. Loved ones can be overlooked. Their treatment needs can be ignored or worse. Now […] Read More
HEALTHCARE TECH CAN SUCK
Health care is the world’s most information intensive industry. It is also plagued by uneven quality, frequent errors and rapidly accelerating costs. The logical conclusion is to computerize everything that doctors and nurses do. The evidence indicates that with computers care is better and safer. Unfortunately, our efforts at computerizing everything is not working. Many […] Read More
HELPING YOUR HEALTHCARE ORGANIZATION TO HANDLE COMPLEXITY:
Healthcare organizations can learn a lot about how to handle complexity from High Reliability Organizations (HROs). Healthcare consumers should demand that the organizations that serve them follow the modus operandi of HROs. HROs operate according to 5 basic principles: 1. track small failures by listening for early signals of failures. 2. resist oversimplification. 3. remain […] Read More
SLOW DOWN THE THINKING PROCESS TO AVOID MEDICAL MISTAKES:
In high velocity environments, like healthcare, speed of decision making is important. The emergency room doctor has to have an immediate response to the motor vehicle accident victim on the gurney in the trauma room. Complex patients with one or many diseases are different. They require doctors to take the time to engage and think […] Read More