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Path"< Truth / Justice / Patient Safety >" is a pathPaths lead from one place to another. In computers they are expressed by a succession of landmarks separated by slashes. <SanFrancisco/Denver/St.Louis/NewYork> would get a Californian to the other coast. Routing determines destinations. We must start with Truth. Otherwise we cannot see the obstacles. If we do not proceed to Justice, we have not overcome them. Patient Safety cannot be reached on the current path, which probably best can be expressed as /TrustUs/. It is not exclusively about trust. However, at the very least, our systems must be able to address issues of trust. If our feedback structures are such that they cannot throttle even unfriendly practices, of what use can they be with regard to subtler issues? At the bare minimum, we must be able to arrive at truth and proceed to justice. The Institute of Medicine defines patient safety as freedom from accidental injury. Apparently when patients are injured on purpose, they still are safe? The Agency for Healthcare Research & Quality, in its Five Steps to Safer Health Care, mentions only steps that help if the caregivers are competent, interested and honest. Sigh. To understand a system you must look at its worst case scenarios. That is where you see how the system operates. In our current system when a patient becomes a victim of an adverse event, the health care system turns on that patient. The system becomes untrustworthy. It circles the wagons to protect itself at the expense of the patient. To see that in its most glaring light, examine instances in which the adverse event is not an accident. Look at what happens when a patient complains of exploitation or abuse. If you want to see how physicians manage to avoid creating records or diagnosing injuries, watch what happens when a patient seeks treatment after being injured intentionally. That is where you get a true picture of the mechanisms by which smaller, more subtle problems do not get prevented or reported in medicine. That is where you see that the most fundamental problem for patient safety is trust - a problem at which no one in medicine even is looking. Without addressing issues of trust, we never are going to make significant progress on the more modest goal of solving accidental injuries. A means for patients to respond to injuries must be put in place, partly because physicians and nurses do not advertise their mistakes. They cover them up. And that has dire consequences for the injured patients. It also makes injuring future patients more likely. Injured patients frequently cannot get diagnosed, let alone treated, because of how unified medical practitioners are in protecting each other. No one wants to create a record that indicts other healthcare professionals. The only recourse patients have had in the past was to travel far enough to find healthcare professionals who did not have access to the network that would damage the career of the practitioner who helped the injured patient. The ability to escape a prejudiced network may be lost with the new electronic health information systems. It could enable iatrogenic injuries to be covered up nationwide more easily than they currently can. Part of what might be necessary is for patients to be given control over their records, like the ability to expunge or seal portions, or possibly all of them. The definition of patient safety and the list of steps to safer healthcare need to include reference to issues of trust. The medical community turns up its nose and does an about-face whenever this is mentioned, but if patient safety initiatives do not address crime they are shallow. The least patients should expect is to be safe from violence and sex abuse and the other abuses in which humans indulge when they believe they can get away with them. Right now you would be hard pressed to find a safer place to abuse people than in medicine. From the outside it looks as though these crimes would be hard to cover up because there are multiple sources for the information about those crimes. It appears that one person could not write a patient's history in a self-protecting way. But patients who have been on the wrong end have watched how accurate histories are prevented from being recorded, and how patients are prevented (sometimes through blacklisting) from being able to get anyone to help or listen. There is little worth salvaging from current feedback structures. A new architecture has to be erected. Initially it will have to be outside the institutions currently charged with truth, justice and patient safety as they will not do it no matter how clear the problem. With an unrecognized, self-serving, self-deception they brush off statistics and examples as being unimportant or unbelievable or too rare with which to be bothered. What are the obstacles?The people who know the obstacles best, injured patients, are sued if they speak (see freedom of speech for patients). The culture of silence (see silence versus safety and risk management) prevents the worst problems from being reported by healthcare professionals. And there is no other source for the most necessary information to form a clear picture. There is little appreciation of the extent to which the data is corrupt. Even with the publication of studies, like the Health and Human Services 2010 report showing that only 2% of adverse events are accurately recorded, health care professionals march on basing their decisions on the inaccurate records. The patient safety movement is working hard on efforts that cannot solve the real problems, meanwhile dismissing the issue that is the bellwether for all of patient safety - crime in medicine. As long as we do not have structures capable of discovering and responding to that, we don't have structures sufficient for dealing with anything in a meaningful way. Crimes rarely are reported. The patients who are injured rarely are recognzied, let alone helped. Patients continue to die unnecessarily year after year and will continue to until this changes. Medicine continues to be a virtually lawless place where witnesses do not report even rape and homicide (see Orville Lynn Majors), victims are sued into silence and offenders operate with impunity. The extent to which this is true is something to which the patient safety movement is oblivious. The stories that make patient safety issues understandable are not allowed to be told. I have been forced to remove them from this site. And numbers, like the amount of assault, rape and homicide in medicine, are brushed off as though they are not important. Patient safety is a path. We must start with knowing what's true. That is what mandatory reporting laws were passed to address, but, as was predicted on this site, no one obeys those laws. That, perhaps, is the first issue of trust that should be addressed. The information gathering system must expand so that a self-interested health care professionals who are loyal to each other are not the only source. Currently, sufferers of iatrogenic injuries cannot even get their stories in the record, whether the injuries were inflicted accidentally or not. And those injured patients are not merely left behind but are crushed and defeated by dishonest operators in a system that has no checks or balances in the realm of these issues. Yet I defy you to find someone in medicine who understands this. They have a culture of rationalizations that allow them to define what they are doing in self-serving ways, and to prevent information to the contrary from reaching them. Ye Shall Know the Truth
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