Learning from Mistakes to Improve Patient Safety

An opinion piece published earlier this month in the Wall Street Journal is an impassioned plea for greater accountability among physicians and greater engagement by patients all in the name of dramatically improving medical care and patient safety.

The piece by Dr. Marty Makary, a surgeon at Johns Hopkins, begins with a striking assertion: “medical mistakes kill enough people each week to fill four jumbo jets,” he writes. “But these mistakes go largely unnoticed by the world at large, and the medical community rarely learns from them.”
Makary’s solution? Better professional practice combined with a more attentive and engaged public.

His professional practice recommendations are, in many cases, simple common sense. He calls for more careful attention to basic details – such as hand-washing and double checking that medical teams are performing the right procedure on the correct part of the body before the procedure begins. He also urges hospitals and doctors alike to focus on understanding their mistakes with the goal of avoiding repeating them. In many cases, he writes, this can be done through things as simple as increasing the use of shared medical notes and the videotaping of surgical procedures so that when something does go awry it is possible to review the mistake and learn from it.

His plea for a more attentive and engaged public has two parts: a belief that hospitals and individual doctors should be more open with data, posting such things as infection and “bounce-back” rates (the rate at which patients need to be readmitted for unanticipated follow-up treatment) online in an easy-to-understand form, and that patients should then make use of that information. He compares this idea with the requirement that New York City restaurants post their City Health Department inspection score in the restaurant’s window. A medical equivalent, he writes, would give hospitals and individual doctors a powerful incentive to improve their performance and maintain high quality levels. Doctors, he asserts, perform better “when they know someone is checking their work” and patients, in turn, will make better, more informed, choices if they are given access to the results of those checks.

As an Oregon patient safety attorney one can only welcome Dr. Makary’s recommendations. Everyone should want patients to get the best care possible and, for that to happen, everyone – doctors and patients alike – must focus at all times on constantly improving our health care system.

Wall Street Journal via Yahoo! Finance: How to Stop Hospitals from Killing Us