«There was the oncologist who needed the biopsy results for one of her new cancer patients. The biopsies had been done long ago, at another hospital, and the patient couldn’t remember who had done them or what they showed. So the oncologist cold-called all the physicians in the department; when none of them knew the patient, she asked for the names of all the recently retired doctors and called them, too, until she got what she needed.
More recent studies suggested this number was too low, raising it to more than 400,000 deaths per year. If they were a disease, medical errors would now rank as the third leading cause of death in the United States, a 2016 analysis published in The BMJ found, right behind heart disease and cancer.
The Joint Commission, a large accreditor of health-care organizations with a focus on patient safety, studied transitions of care and concluded that they are largely ineffective, leading to adverse events, hospital readmissions, and soaring costs.
The advice usually amounts to this: When the system fails you, be more careful. Work harder.
We can cold-call retired physicians from distant hospitals and we can print rhythm strips to stuff in wallets. Something relevant will eventually go missing. Maybe not this time, and maybe not the next. But as an aggregate, this can’t be counted on as a backbone system of safety. It’s also a waste of resources to rewrite a new chart every time a patient enters a new building. I’ve seen doctors go above and beyond in every possible way and yet I’ve seen how hard it is to always get it right. It’s as engineer W. Edwards Deming said: “A bad system will beat a good person every time.”»
Meta: Holy cow, I thought I was posting a link from The Atlantic, but somehow it got transmogrified into this Undark link. Looks like the same article, so… how did this happen?