Medical errors - and what if they didn't tell us?

Massachusetts General Hospital archives

Dr. Ernest Amory Codman.

We all are aware that, unfortunately, medical errors can and do occur. A recent example is of this New Zealand woman who was never told of her Her2 positive diagnosis for two years and didn't receive the correct treatment until it was too late.

But what if doctors never told us about treatment outcomes and what their error rates were? That would be pretty damn scary. No one likes to admit they made a mistake but as 'to err is human', it does happen.

But that's the way things used to be:

"Dr. Ernest Amory Codman was in his mid-40s when his golden career as a sought-after Harvard surgeon began to unravel. He had quit in exasperation from Massachusetts General Hospital, and when he took his dispute with hospital leaders public, colleagues turned against him. Many stopped sending him patients.

It was the early 1900s, and Codman was impatiently pushing hospitals and doctors to adopt a practice many considered heretical at the time: Record the “end results’’ for every patient — including harm caused by physicians’ errors — and make them public."

But now his work is being recognized:

"A century later, many of Codman’s ideas are the bedrock of modern medicine. And a group of doctors, including a former Mass. General surgery chief, plans to make sure he gets the wider appreciation he deserves this week." 

His work has led to many changes in medical practice, even if he wasn't appreciated during his life time. You can read here the whole story here but think of what medical practice would be like with out people like him pushing for change.

Practice makes perfect

And why its a medical practice. I have had eight surgeries and a billion medical (mis)adventures but I have NEVER asked this question of the person doing the procedure: how many times have you done this procedure? I have never asked that. And this is scary.

A couple of weeks ago I had a filling, a rather large filling to be precise, which is/was borderline for turning into a root canal. I hate the dentist. I hate the drilling and the needles and the potential pain. I am a weinie and have been know to take an ativan pre-procedure to get me through it.

The dentist and I had a big conversation as we waited for the Novocain to kick in. She said if it turned out I needed a root canal she would send me to an endodontist because she didn't do root canals any more. She told me that she said an endodontist would have me in and out  in and hour because that is what they did all day long and they were very good and had the right tools and microscopes and all sorts of fun things I didn't want to hear about it.

Doctors who do the same procedure day in and day out have a much lower rate of errors and mistakes. You really want the doctor who does the same surgery again and again. Go read that article if you don't believe me. But I think its time I start asking questions....

Medical errors - and what if they didn't tell us?

Massachusetts General Hospital archives

Dr. Ernest Amory Codman.

We all are aware that, unfortunately, medical errors can and do occur. A recent example is of this New Zealand woman who was never told of her Her2 positive diagnosis for two years and didn't receive the correct treatment until it was too late.

But what if doctors never told us about treatment outcomes and what their error rates were? That would be pretty damn scary. No one likes to admit they made a mistake but as 'to err is human', it does happen.

But that's the way things used to be:

"Dr. Ernest Amory Codman was in his mid-40s when his golden career as a sought-after Harvard surgeon began to unravel. He had quit in exasperation from Massachusetts General Hospital, and when he took his dispute with hospital leaders public, colleagues turned against him. Many stopped sending him patients.

It was the early 1900s, and Codman was impatiently pushing hospitals and doctors to adopt a practice many considered heretical at the time: Record the “end results’’ for every patient — including harm caused by physicians’ errors — and make them public."

But now his work is being recognized:

"A century later, many of Codman’s ideas are the bedrock of modern medicine. And a group of doctors, including a former Mass. General surgery chief, plans to make sure he gets the wider appreciation he deserves this week." 

His work has led to many changes in medical practice, even if he wasn't appreciated during his life time. You can read here the whole story here but think of what medical practice would be like with out people like him pushing for change.

Practice makes perfect

And why its a medical practice. I have had eight surgeries and a billion medical (mis)adventures but I have NEVER asked this question of the person doing the procedure: how many times have you done this procedure? I have never asked that. And this is scary.

A couple of weeks ago I had a filling, a rather large filling to be precise, which is/was borderline for turning into a root canal. I hate the dentist. I hate the drilling and the needles and the potential pain. I am a weinie and have been know to take an ativan pre-procedure to get me through it.

The dentist and I had a big conversation as we waited for the Novocain to kick in. She said if it turned out I needed a root canal she would send me to an endodontist because she didn't do root canals any more. She told me that she said an endodontist would have me in and out  in and hour because that is what they did all day long and they were very good and had the right tools and microscopes and all sorts of fun things I didn't want to hear about it.

Doctors who do the same procedure day in and day out have a much lower rate of errors and mistakes. You really want the doctor who does the same surgery again and again. Go read that article if you don't believe me. But I think its time I start asking questions....

The patient hand off

How many times have you been the patient and been handed off from one shift to the next? And  how often does that happen in a slightly overheard conversation between one nurse and the next or one doctor to the next? There never seems to be a formal system of it and it always seems to be rushed. It is a key place where misunderstandings over a patient's care can occur which result in medical errors.

I have learned things about my care from hearing the nurse tell the next nurse that my gall bladder surgery did result in some fairly significant internal bruising during the surgery. The nurse had previously told me that it wasn't that bad and should clear up in a day or two. I also learned that during my knee surgery I had become agitated during the surgery for an unknown reason and should be watched in case I was having a problem with the anesthesia. During a hospitalization I learned that I was doing well but my pain levels were running a little high (I already could tell them that).

Little rushed conversations in the corner or on the side of a busy hallway while updating a patient's file are not in the best interest of the patient. Especially if the nurse tells the next nurse about several patients without time for note taking - can  you say confusion?

Children's Hospital in Boston has come up with a team approach where the full team participates. This has cut medical errors in half. Maybe I should be a kid again and  go there for my next procedure? Or I hope that other hospitals follow suit.