A patient is admitted to the hospital with 'complications.' Two doctors (specialists) separately prescribe medication causing "significant harm" when taken in combination. Is this medical error attributable to the specialists (medical malpractice), or is the error a systems failure?
It seems most today argue the error is a systems failure. I want to argue that the problem is not solely a systems problem. It is also a problem of culture, a problem deeply engrained in the culture of medicine as it is practiced today in the US, and as it is increasingly practiced around the world.
Let's first begin at the end of the chain with the occurrence of medical error and work our way back to the source of liability. The case study stipulates that a medical error has taken place in the form of medication error. The medication error is one of overuse, i.e., doctors (specialists) have separately prescribed two medications that cause significant harm when taken in combination.
Now, this is where the argument becomes complex, because it involves “miscommunication” coupled with a “failure to communicate.”
We presuppose that the patient in the case study consents to a prescription from each of the doctors (specialists) based on “incomplete information.” The “incomplete information,” in turn, is the result of a “lack of a unified diagnosis.”
Here is the source of the miscommunication: the patient believes he/she has “complete information” based on a “unified diagnosis” when he/she does not.
So, we begin with a “lack of a unified diagnosis” and work our way backward along the chain that leads forward to the end result, medical error in the form of medication error.
The question we must address here is: What is the cause of the “lack of a unified diagnosis”? I believe this is where a “failure to communicate” becomes relevant in the case study.
Because the doctors (specialists) in the case do not communicate with one another, as a consequence, they do not coordinate their efforts in the care of the patient. Because they do not coordinate their efforts, the two specialists separately prescribe medications that are contraindicated causing significant harm to the patient.
So, now the question becomes, what is the cause(s) of the error. Is someone to blame; is it a “systems failure”; or something else in addition?
I propose we must first seek an answer to the question: What is the cause of a “failure to communicate”? Why don’t the doctors (specialists) coordinate their efforts? Is that a systems problem?
A fragmentation of care (component management)—a doctor for every organ—is clearly a root cause. In the case, there is no “captain of the ship." Because no captain, no coordination; because no coordination, medication error as overuse.
Granted no 'captain,' still the question remains: Why don’t specialists talk to one another? Why don't they coordinate their efforts in the care of a patient?
I don’t think that efficiency of systems will of itself solve this problem. The problem involves issues of reimbursement, issues related to hospital politics, and, finally, issues related to the culture of medicine.
In specialization, med students are trained not to interfere with the work of other specialists. It’s simply the way medicine is practiced today in the US. Some call it episodic intervention: when something happens to an organ system, the patient sees a specialist in that organ system; when something happens to another organ system, the patient sees a specialist and subspecialist for that organ system, and so forth.
As a consequence, no one looks after the whole patient.
Unless and until we become willing to address systems issues, together with reimbursement issues, hospital politics, and the culture of contemporary medicine, patients/caregivers will continue to be forced to take on the job of "captain" of their own ship, a truly daunting task!
To end with an answer to the question, ultimately IMHO, the source of the medication error in the case study is the failure to communicate among doctors (specialists) in failing to coordinate their efforts in the care of the patient.
Let's first begin at the end of the chain with the occurrence of medical error and work our way back to the source of liability. The case study stipulates that a medical error has taken place in the form of medication error. The medication error is one of overuse, i.e., doctors (specialists) have separately prescribed two medications that cause significant harm when taken in combination.
Posted by: cheap jerseys | September 07, 2011 at 01:43 AM