And on the eighth day, He couldn’t believe what He had just done…
We ought to learn more from our mistakes than from what we would qualify as successes. In fact it’s not a bad idea to carefully maintain a dairy of complications that one encounters in addition to the ubiquitous logbook. Complications, unexpected adverse events, errors in judgment and technique, logically analyzed, anonymised and recorded over the years should be a great personal treasure to any surgeon. When compiled and edited – may be for all.
A good analysis is not a blame-game. There are no accusations, no confessions, no names, no apologies- just cold, logical assessment of the sequence of events that lead to an undesirable event and the actions that could have prevented it at each step, but didn’t.
Medical care review meets [mortality meets] suffer from accusatory overtones, compulsion to pass judgement, ‘us-against-you theatrics’ and hence, the defensive dilution of candid declaration of errors. It serves very little purpose in its present form. What happens is an unnecessary detailed presentation of clinical findings, investigations and procedures, all smoothened out to paint a picture of inevitable, apparently uncontrollable cascade of events leading to death of the patient. And is death the only undesirable outcome? Isn’t morbidity a more living problem? Is anything learned? Nothing is more volatile than memory of the last mortality meet. And a few weeks later - déjà vu!
Sometimes one wonders – may be physicians should have interaction with business management guys – failure analysis, root cause analysis, Ishikawa’s fishbone…The result of any failure analysis should be solid recommendations that do result in change in practice. Not the usual knee jerk response to an event in recent memory that dwarfs better judgement formed over years of clinical practice and trials.
Tons have been written on good techniques. Terabytes of operative videos. But what is transparent (invisible) to the onlooker are the hundreds of possible steps that the expert surgeon hasn’t taken each time, which avoided a future complication. For every ‘!!’ move there are a million ‘??’ moves that would have got you checkmated…
And not for a moment let us think that we have the greatest responsibility. A bus driver taking fifty sleeping passengers on a dark highway or the pilot flying through a thunderstorm has more at stake. He better have a good breakfast and sound sleep.
A good analysis is not a blame-game. There are no accusations, no confessions, no names, no apologies- just cold, logical assessment of the sequence of events that lead to an undesirable event and the actions that could have prevented it at each step, but didn’t.
Medical care review meets [mortality meets] suffer from accusatory overtones, compulsion to pass judgement, ‘us-against-you theatrics’ and hence, the defensive dilution of candid declaration of errors. It serves very little purpose in its present form. What happens is an unnecessary detailed presentation of clinical findings, investigations and procedures, all smoothened out to paint a picture of inevitable, apparently uncontrollable cascade of events leading to death of the patient. And is death the only undesirable outcome? Isn’t morbidity a more living problem? Is anything learned? Nothing is more volatile than memory of the last mortality meet. And a few weeks later - déjà vu!
Sometimes one wonders – may be physicians should have interaction with business management guys – failure analysis, root cause analysis, Ishikawa’s fishbone…The result of any failure analysis should be solid recommendations that do result in change in practice. Not the usual knee jerk response to an event in recent memory that dwarfs better judgement formed over years of clinical practice and trials.
Tons have been written on good techniques. Terabytes of operative videos. But what is transparent (invisible) to the onlooker are the hundreds of possible steps that the expert surgeon hasn’t taken each time, which avoided a future complication. For every ‘!!’ move there are a million ‘??’ moves that would have got you checkmated…
And not for a moment let us think that we have the greatest responsibility. A bus driver taking fifty sleeping passengers on a dark highway or the pilot flying through a thunderstorm has more at stake. He better have a good breakfast and sound sleep.
1 comment:
thought vector: i think it is time doctors got out of 'Im God- I can do no wrong' attitude.
Having now seen t workings of a different health care system...on which i should say NIMHANS was born (tho it has gone way overboard with more managers than doctors!!..well i can go on about the falacies of the NHS!! but will save it for another day)But what it does do is create accountability.....
I think these blogs and thoughts are the beginnings of clinical governance emerging in india....
but be warned....it is very easy to let it run amock like it has in western practices....mabbe we can get it right in India!!
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