Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Airplanes, Streisand, and Patient Safety

Addressing the topic of treatment errors, at EMS Patient Perspective Bob Sullivan writes about ways to deal with our inevitable errors. It isn’t just the errors of others that we should be considering. Our errors are inevitable, too. As many people have pointed out, anybody who claims to be free of errors is incredibly inexperienced, is incredibly naive, or is telling a lie. Maybe all three.

I know what some of you are thinking –

But if we don’t severely punish errors, we are encouraging errors!

This is nonsense.

This just results in people covering up their errors. Everyone makes errors, so 100% error free is impossible. Even the Six Sigma claim of only 3.4 errors per million plus actions is hopelessly optimistic.[1]

A lot depends on what we classify as an error. We make mistakes every day. Maybe we should change the name of our species from Homo sapiens (wise man) to the more accurate Homo errant (mistaken man) or Homo fraudulenti (deceitful man).

We make mistakes, but to create the impression of perfection, we aggressively punish the mistakes of others and we even more aggressively cover up our own mistakes. This is unethical and dishonest, but it is likely to produce far more mistakes than any less punitive system for dealing with errors.

Considering the possibility of filming all of our actions in EMS, Bob writes –

So imagine what non-punitive, collaborative reviews of patient care in the back of an ambulance could do. I would gladly narrate a video of the cardiac arrest I got in trouble for to explain what I was thinking at each step, where we got off track, and how that error could be prevented in the future. If this was widely practiced, how many other mistakes could be avoided? How much better would our care be?[2]

non-punitive?

But we must have the ritual sacrifice of the person who is not politically well connected. How else can we convince those, who are ignorant of what we really do, that we know what we are doing?

If we do not punish errors, we feel inadequate.

Consider just how pathetic that is.

We would rather punish errors than educate. Punishment is not education. Punishment is how we deal with our failure to educate or our failure to supervise. Punishment teaches others that we are incompetent at education.

Errors are unintentional. Punishment is only appropriate for things that are intentional. The distinction is important.

collaborative?

Having everyone work at improving quality, rather than the methods of Stalin and Hitler of having informants report the mistakes of others and also punishing those who do not report every mistake?

That would require maturity. We only fake it when it comes to maturity.

If this sounds intimidating at first, it should. It would require our profession to grow up. We would take responsibility for the care we give and the care given by the people we certify.[2]

EMS grow up?

That is an idea that deserves to be punished./

For even suggesting it we should punish Bob Sullivan. What other evil ideas will he come up with at EMS Patient Perspective?

Footnotes:

[1] Six Sigma
Wikipedia
Article

A six sigma process is one in which 99.99966% of the products manufactured are statistically expected to be free of defects (3.4 defects per million).

[2] Airplanes, Streisand, and Patient Safety
EMS Patient Perspective
Article

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Comments

  1. I’m just getting warmed up….

  2. In an ideal world, we would be encouraged to share our mistakes in order to develop checks and balances to avoid those mistakes in the future. I’ve seen the statistics on med errors alone (never mind other errors) and they are maddening. The fact is, no one in EMS/healthcare sets out to kill someone when they start their day – it’s so obvious that these mistakes and accidents happen. We should be working in environments where people come forward and say, this happened and this is why, and here a new/better/different way it could be avoided in the future.
    This isn’t at all a matter of ‘growing up’, (that description makes me cringe since it’s not even relevant, nor is it productive in promoting change); it’s a matter of creating a work environment where healthcare providers feel secure enough to come forward in the name of a safer big picture. I don’t know how we get there as a profession, but I do know that my local healthcare facilities are encouraging us to speak up when things go wrong, without repercussions in terms of job loss/suspension.

  3. “But we must have the ritual sacrifice of the person who is not politically well connected. How else can we convince those, who are ignorant of what we really do, that we know what we are doing?”

    Of course it’s this line of thinking that usually quiets the dissenters of the local mythology. Fire a few outspoken people that challenge the system, and the majority will revert to lemming status. Of course this leads to an all new problem; that of errors by omission.

    I’ve seen far too many people on the ambulance that are thought of as “good” medics, simply because they do the same thing for every patient. You know the type… chest pain call? IV, O2, EKG, BG and transport. Seizure? IV, O2, EKG, BG and transport. Twisted ankle? IV, O2, EKG, BG, and transport. Do you see a trend here?

    I had to ride with a probationary medic that did this very routine on every call. Apparently certain people in the administration felt she was more than adequate, if not a downright model of paramedicine. They could not figure out why she was receiving low marks from various proctors. Of course with admin being admin they failed to see that this particular medic had absolutely no idea WHY she did any of these things. She simply did them because she was told to at some point in her (mis)education. God forbid that any of these patients might need some actual treatment or a bit of thought as to what might be causing their problem that particular night. Admin LOVE these types of people. Everyone is transported; everyone is charged at ALS rates due to IV and EKG; and most importantly, there is no complaining or whining about evidence based medicine or ways to improve patient care. It’s a win-win for the admin types.

    My point to all of this is that when we work in an environment that discourages discussion of errors, we will find more and more medics treating all patients just like the one mentioned above simply to avoid the possibility of doing something wrong. Never mind what might be the root cause, at least you covered your ass by doing all of the things listed in the protocol book as standing orders. How can I possibly get in trouble now?

    And in response to Miss Sugarpants (love the name by the way), calling on EMS to grow up is spot on in most cases. I’m sure there are some places doing things right and making improvements, improving patient care, and reducing errors. The problem is that overall EMS spends too much time bickering over childish disputes like private vs public, fire vs third service, medic vs basic, and so forth and so on. Until we act a bit more mature on the whole, I just don’t see things really improving much.

    Sorry to rant on your blog, but at least the peeps here can feel my pain.

    • I think that paramedic did not understand the concept of benign neglect.

      I too often ride with cookbook medics out of school, and it is a bit disappointing. They’re the ones that look at me funny when I withhold oxygen on an attempted hanging (he’s talking to us…I don’t think he needs oxygen) or run a 12-Lead on a pediatric syncope.

      I never really believed it in school, but our lead instructor kept telling us we needed to focus more on the knowledge and less on the skills. He claimed he could find a pack of monkeys to replace us if all we wanted to do was start IV’s and intubate.

      • The problem where I live is that the instructors do the exact opposite. They encourage the cookbook approach and offer no in depth knowledge. It’s basically a medic mill under the guise of a state funded community college. But I do agree with your instructor and his monkey analogy.

        In my example above the poor girl that I rode with was completely clueless. The chief complaint was whatever the call was dispatched as. In other words if you went on a shortness of breath call and arrived to find a hypoglycemic diabetic, she would write down “short of breath” as chief complaint on the PCR. Her reports to the hospital were even worse. She seriously had no idea what she was doing, but she smiled, patted people on the shoulder, and applied the alphabet soup of diagnostics to every patient. Never mind what any of those findings might reveal or indicate.

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