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 inertia is to do with while focusing only on systems and processes and ignoring 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. 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.

The evidence needed for RCA is not available unless frontline workers in medicine happen not to mind collecting it. When they do, it will be information about problems that need to be solved, but that do not address the root causes for why so many patients die unnecessarily (some even murdered) in medicine each year.

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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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