Full Table of Contents
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Abbreviated
Table of Contents

Home Page
Patient Safety
Silence vs
    Safety
Silenced
White wall
    of Silence
Silencing
Conflict Of
    Interest
Psychology of
    Providers
Subjectivity
Blacklisting  
Nurse survey
Loyalty
Mobbing and
    bullying
Trust Us
Defensive
    documenting
Report Rate
Risk
    managemnt
SOAP
Management
Hospitals
Crime in
    medicine
Sexual Abuse
Liability
    Limitations
Free Speech
    for Patients
Exploitation

OSMB Medical
    Boards
Mammography
solutions
Medical errors
Medical
    Complaints
One number
Links

Injured patients who want to help and be heard, click here.

Thomas Jefferson said that given the choice between government without newspapers and newspapers without government, he would choose to have newspapers.

In medicine we have government without newspapers. Patients cannot find out what they need to know to make informed choices. No one in medicine records or reports the information patients need to know the most. So patients will have to.

Notes 6

These are notes linked to from other pages on this site

4.1%
In a recent given year, 4.1% of sentinel events in medicine were assault/rape/homicide according to the Joint Commission on Accreditation of Healthcare Organizations.

They also found that medical facility employees proved the least likely source for identifying a sentinel event (less than 1% of the total cases).

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Sentinel Event
According to the Joint Commission on the Accreditation of Healthcare Organizations, (JCAHO, pronounced Jayco) a sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase, "or the risk thereof" includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. Such events are called "sentinel" because they signal the need for immediate investigation and response, which is exactly the what healthcare organizations do not want (see risk management). They want to appear to be 100% safe and they want to incur no liabilities as a result of preserving evidence or creating records of errors and crimes. People in healthcare organizations are trained to avoid creating records of such events. Systems are organized to defeat even remembering such events.

Root cause analysis (RCA)
Root cause analysis generally is applied to an adverse event that already has occurred and works backwards to find factors that underlie variation in performance. In medicine the current belief is that only systems and processes are the problem and so they ignore variations in individual performance. That is how it is stated in the guidelines of JACHO. "Not individual performance." Since patient safety is run by healthcare professionals, throughout medicine there is a strong disinclination to identify problem personnel or find fault with any healthcare professionals. Some regard this as institutionalizing covering up. Like in the case of Genene Ann Jones and other cases listed in the Table of Contents.

Root cause analysis requires evidence. There is scant little of that for most adverse events because people in medicine will not report them. Medicine is a field in which even the treatments and procedures used often are backed up by little or no evidence to substantiate their effectiveness or their desirability over other options (see Mammosite, for one). In most cases there isn't even long term tracking of patients to see how various operators or procedures effect them. It is a culture that not only is not interested in evidence, but that even has habits and procedures designed to prevent collecting evidence - after all, they repeat, "you have to protect yourself from lawsuits."

Two of the things they suggest are in line with chief themes of this web site:
1) An official Patient Safety Organization to serve as a repository of analyses and solutions and with the power to negotiate fixes.
2) The added value of including patient input in the RCA process.

Health care workers will not report most of what goes wrong. It has been demonstrated that patients will report more verifiable information than health care workers when given the opportunity. Health care workers are aware of far more than patients, but will report almost none of it when it is negative. Patients are aware of far less, but will report all of it, in the end reporting a greater quantity of accurate, verifiable information than can be gotten from the health care workers. (See Annals of Internal Medicine article about Unnecessary Patient Deaths)

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Legitimate grievances resulting in suits
Harvard researcher Dr. David Studdert in a 1999 study of 14,700 medical charts found that of the patients who suffered negligent injury, 97% did not sue.

Studdert studied only the legitimate grievances of which there was a written record. If the he had been able to include the number of legitimate grievances of which no record was made, the number of victims who were able to get lawyers would be a small fraction of one percent.

How "no-fault" and blameless can a system be?

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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

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It's a path

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Site revised November 29, 2011