Recorded at USC Grand Rounds.. Mike gives some badly needed perspective to Medical Error. I know I always say you need to listen to this... but this segment you REALLY need to listen to.
To view chapter written summaries, you need to subscribe.
What is the feed or the OPML address for this podcast? I have to enter it in manually on my iPad. Neither Settings button nor refresh button exist or I cant find them in iTunes...
to access this podcast via iTunes please click on the link on the bottom right of this page. You will be prompted to enter your email address and password for this website.. that will auto magically set up the podcast in your iTunes for you.
every single patent has a problem, every single one will die... at some point. every plane does not have a problem, every plane will not crash. that is the biggest problem with the analogy of health care to the airline industry.
EMRA members should still be able to subscribe to iTunes podcast the same way as any other subscriber. Click on the link to the right and enter your login info EXACTLY as you have to login to this site. That should get your podcast subscription active.
I have been a pilot for 34 years and a ED physician for 20 years. I like what Mike said but he does not understand aviation, its processes or the safety relationship. The fallacy that safety in aviation is marginal versus absolute is just wrong. The only problem with the aviation/medical analogy is that when you make an error in aviation you are at risk of dieing too. Aviation safety is based upon checklists and open discussion of errors and then learning from them and forcing training of the new protocols. It is much more complex than that but to dismiss the opportunity to improve because we are using the "wrong model" is not the right answer.
Continuing, Aviation safety is not based on not making the flight when the weather is bad, it is making sure (and double checking) that everything necessary for the flight is ready. It is following procedures exactly and having systems that are clear, concise and as error free as possible. There are always opportunities for improvement so it includes the incorporation of those opportunities when they are identified. Most of our M and M's are of the "that could have been me". They don't address the actual causes of the errors. We have a robust EMR where I work but it introduces a million new ways for me to make an error while saving me a thousand old ways from doing so. The difference is that most of the old ways were more dangerous than the new ways. Dismissing the opportunity to improve patient safety is throwing the baby out with the bathwater (even though I agree with some of the report analysis).
A better analogy of medicine and aviation would be one in which the airplane is already crashing or in trouble (like how most of our patients present to the ED). THEN AFTER we've tried to save the plane, getting blamed for the accident as a whole.
I also disagree to a certain extent with the lecturer's comment that "We need to move away from the idea that mistakes are the fault of the individual and focus on the system."
It depends on which "individual" you are referring to. I would like to see a focus on placing the responsibility of health care back on the patient.
Why should I be blamed or even better why CAN I be blamed for a bad outcome in a non-compliant DKA, COPD or CHF pt. if my treatment wasn't "perfect?" It was THEIR choice/decision to not follow medical advice and continue to smoke, or not take their medications as prescribed.
Biggest problem has nothing to do with analogy (although if we start distinguishing diseases of "sin" vs. innocents, it's a bad slope).
Biggest problem is the 3%: "that's not so bad." Wait- 1 out of 33 of my pts. should get a medical error? That's something like a few a week. So 13% will die? So I'm killing a pt. an estimated once a month? And I've been working 15 years. Holy @!#$. But don't worry, of course it's someone ELSE's 3%. YOU're not the problem, no, course not.
When docs were told that iatrogenic infection rates were "only" 2-3% they also said it was impossible to expect better. Very basic attention now puts the routine catheter assoc. infection rate b/tw .5 and 1%, and the good places are at 0.2-0.3%.
Biggest problem is arguing about planes and getting defensive instead of accepting that perhaps we could do it better.
Don't get me wrong, there are cases we have no shot at, and also cases where heuristics totally save you. But we have to be vigilant not to worship the efficiency of the heuristic and sacrifice the consideration that we might be wrong. Incorporating an understanding of cognitive error into clinical decision making and M+M can only help.
We've had aviation people come in to our institution and give a similar lecture. Afterwards. I asked one of them:
Me: When there's too many people to put on the plane, do you just pack them all in and take off anyway? Him: No, of course not. Me: Well, we do. When all the equipment isn't in perfect working order, do you just take off anyway? Him: No. Me: Well, we do. When you don't have enough people to crew the plane or staff airport operations, do you just take off anyway? Him: No. Me: Well, we do. When you're in flight, are you constantly confronted with about 2-4 completely new problem situations per hour, constant interruptions, and the virtual certainty--not possiblity, but certainty--that you will be presented with a life-threatening emergency at some point in the next 8-12 hours? Him: No, not really. Me: Nice talkin' to ya.
The analogy between the airline industry and emergency medicine quickly falls apart. There is much we can learn from industries--and much we will resist learning. Giving lip service to safety and hiring fancy speakers to come in and give pep talks is always cheaper than putting boots on the ground. Emergency medicine has more in common with military/police/fire institutions than with other commercial enterprises.
Very belated post here; I got around to this episode 9 months late. I have nothing of substance to add, previous comments were well-reasoned and thoughtful. I DO want Mel to know that yes, I recognized 'Urgent,' as well as 'Cold as Ice,' the latter after only a half-second of audio. Keep up the good work. Kudos from the Class of '78!
To join the conversation, you need to subscribe.
Sign up today for full access to all episodes and to join the conversation.
e c. - February 3, 2012 10:42 AM
What is the feed or the OPML address for this podcast? I have to enter it in manually on my iPad. Neither Settings button nor refresh button exist or I cant find them in iTunes...
tom w. - February 8, 2012 10:36 AM
to access this podcast via iTunes please click on the link on the bottom right of this page. You will be prompted to enter your email address and password for this website.. that will auto magically set up the podcast in your iTunes for you.
john v. - February 8, 2012 1:32 PM
how about resident members still using our free EMRA access to EMRAP? Any hope for us or are we stuck manually adding each episode?
brendan c. - February 9, 2012 9:38 AM
every single patent has a problem, every single one will die... at some point.
every plane does not have a problem, every plane will not crash. that is the biggest problem with the analogy of health care to the airline industry.
tom w. - February 23, 2012 8:58 AM
EMRA members should still be able to subscribe to iTunes podcast the same way as any other subscriber. Click on the link to the right and enter your login info EXACTLY as you have to login to this site. That should get your podcast subscription active.
James M., M.D. - February 25, 2012 2:38 PM
I have been a pilot for 34 years and a ED physician for 20 years. I like what Mike said but he does not understand aviation, its processes or the safety relationship. The fallacy that safety in aviation is marginal versus absolute is just wrong.
The only problem with the aviation/medical analogy is that when you make an error in aviation you are at risk of dieing too.
Aviation safety is based upon checklists and open discussion of errors and then learning from them and forcing training of the new protocols. It is much more complex than that but to dismiss the opportunity to improve because we are using the "wrong model" is not the right answer.
James M., M.D. - February 27, 2012 8:44 PM
Continuing, Aviation safety is not based on not making the flight when the weather is bad, it is making sure (and double checking) that everything necessary for the flight is ready. It is following procedures exactly and having systems that are clear, concise and as error free as possible. There are always opportunities for improvement so it includes the incorporation of those opportunities when they are identified. Most of our M and M's are of the "that could have been me". They don't address the actual causes of the errors.
We have a robust EMR where I work but it introduces a million new ways for me to make an error while saving me a thousand old ways from doing so. The difference is that most of the old ways were more dangerous than the new ways.
Dismissing the opportunity to improve patient safety is throwing the baby out with the bathwater (even though I agree with some of the report analysis).
J. Thompson D.O. - March 2, 2012 8:24 PM
A better analogy of medicine and aviation would be one in which the airplane is already crashing or in trouble (like how most of our patients present to the ED). THEN AFTER we've tried to save the plane, getting blamed for the accident as a whole.
I also disagree to a certain extent with the lecturer's comment that "We need to move away from the idea that mistakes are the fault of the individual and focus on the system."
It depends on which "individual" you are referring to.
I would like to see a focus on placing the responsibility of health care back on the patient.
Why should I be blamed or even better why CAN I be blamed for a bad outcome in a non-compliant DKA, COPD or CHF pt. if my treatment wasn't "perfect?"
It was THEIR choice/decision to not follow medical advice and continue to smoke, or not take their medications as prescribed.
IUswimr - March 7, 2012 11:34 AM
Biggest problem has nothing to do with analogy (although if we start distinguishing diseases of "sin" vs. innocents, it's a bad slope).
Biggest problem is the 3%: "that's not so bad." Wait- 1 out of 33 of my pts. should get a medical error? That's something like a few a week. So 13% will die? So I'm killing a pt. an estimated once a month? And I've been working 15 years. Holy @!#$. But don't worry, of course it's someone ELSE's 3%. YOU're not the problem, no, course not.
When docs were told that iatrogenic infection rates were "only" 2-3% they also said it was impossible to expect better. Very basic attention now puts the routine catheter assoc. infection rate b/tw .5 and 1%, and the good places are at 0.2-0.3%.
Biggest problem is arguing about planes and getting defensive instead of accepting that perhaps we could do it better.
IUswimr - March 7, 2012 11:39 AM
Don't get me wrong, there are cases we have no shot at, and also cases where heuristics totally save you. But we have to be vigilant not to worship the efficiency of the heuristic and sacrifice the consideration that we might be wrong. Incorporating an understanding of cognitive error into clinical decision making and M+M can only help.
Sunil A. - March 16, 2012 3:57 AM
For the first question on the page ... the OPML Address is
www.emrap.org/podcast.xml
This is useful for manually adding the podcast to non-itunes based podcast manager (ipod / ipad / android)
Jonathon S., M.D. - June 10, 2012 11:55 AM
We've had aviation people come in to our institution and give a similar lecture. Afterwards. I asked one of them:
Me: When there's too many people to put on the plane, do you just pack them all in and take off anyway?
Him: No, of course not.
Me: Well, we do. When all the equipment isn't in perfect working order, do you just take off anyway?
Him: No.
Me: Well, we do. When you don't have enough people to crew the plane or staff airport operations, do you just take off anyway?
Him: No.
Me: Well, we do. When you're in flight, are you constantly confronted with about 2-4 completely new problem situations per hour, constant interruptions, and the virtual certainty--not possiblity, but certainty--that you will be presented with a life-threatening emergency at some point in the next 8-12 hours?
Him: No, not really.
Me: Nice talkin' to ya.
The analogy between the airline industry and emergency medicine quickly falls apart. There is much we can learn from industries--and much we will resist learning. Giving lip service to safety and hiring fancy speakers to come in and give pep talks is always cheaper than putting boots on the ground. Emergency medicine has more in common with military/police/fire institutions than with other commercial enterprises.
John J. - November 16, 2012 7:50 AM
Very belated post here; I got around to this episode 9 months late. I have nothing of substance to add, previous comments were well-reasoned and thoughtful. I DO want Mel to know that yes, I recognized 'Urgent,' as well as 'Cold as Ice,' the latter after only a half-second of audio. Keep up the good work. Kudos from the Class of '78!