Institutional Reporting

Autopsies as an example

An overwhelming portion of what is known about our bodies and diseases was discovered through autopsies. Autopsies might be the greatest learning and error prevention tool that there is in medicine. When autopsies are done they uncover missed or incorrect diagnoses in up to 25 percent of hospital deaths, but hospitals are afraid of being sued when those mistakes are discovered. So they don't do autopsies much. In the 1940s, about half of Americans who died were autopsied. The rate now is less than 5%. They have been pressured to do more, but consistently found ways not to. That is a refusal to find or report information essential to the wellbeing of patients.

(JCAHO, pronounced Jayco) tried to get hospitals to autopsy suspicious or unexplained or unusual deaths in order to learn from them. To try to encouraged that they used to require that 20% of hospital deaths be autopsied. But hospitals don't like to find problems and circumvented JCAHO's efforts by doing only random autopsies. That way most of the problems did not get noticed. They were able to meet JCAHO's 20% requirement without finding most of the problems. Eventually JCAHO gave up and dropped the requirement, which is too bad because even the random autopsies would have taught us something. I guess that gives some credence to the critics who say that JCAHO is more lapdog than watchdog.

Another major study examined 1000 autopsies between 1983 and 1988 and found that there were "'major discrepancies' between the autopsy findings and the clinical diagnosis in 317 cases." But now that we do so few autopsies, we'll never learn where those errors are being made. We'll just keep making the those mistakes over and over.

Neither the institutions nor the personnel are investigating or reporting
that which is necessary to reduce error and abuse.
This is not new. It was the same 100 years ago (see oversight).

There never will be an environment in which there are no penalties for reporting. The penalties for failing to report are large, but only for the patients, not for those refusing or failing to report. It is the patients who die or get raped. Hospitals and healthcare workers benefit from refusing to acknowledge or failing to notice abuse and error. So someone else will have to notice, someone whose livelihood is not improved by not noticing. And when someone does notice, they must be protected from reprisal. Currently if the victim or anyone else speaks, the reprisals brought by hospitals and healthcare workers are life-ruining. (See freedom of speech for patients).

Home | Table of Contents | It's a Path
Silence versus Patient Safety
Loyalty versus Patient Safety
The White Wall of Silence versus Patient Safety
Blacklisting Patients
Freedom of Speech for Patients
Medical Complaints - How to

* * * * *    < Truth / Justice / Patient Safety >    * * * * *
It's a path

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Revised August 18, 2008