|
Judith Rosen wrote:
Wow! A whole bunch of questions arose over this post of yours... One is;
"How did he arrive at his estimates for the # of deaths due to medical
errors???" I have a hunch that those numbers are just the tip of the iceberg.
The estimates in the IOM
report of deaths nationwide due to medical errors were an extrapolation from a
Harvard Medical Practice Study of care in a number of hospitals in MA in the
1980's. (Their methodolgy was to have MD's review care in which there was
a bad outcome and rate whether they thought there was negligence. One
weekness of the study is that the interobserver agreement regarding negligence
wasn't very good.) It is generally recognized that the confidence intervals
around these estimates are pretty wide, but most would agree that even if they
are off by a factor or 3 or 4 (either too high or too low) that there are too
many deaths attributable to medical errors and that ways should be found to make
medical care safer.
Tom
----- Original Message -----
Sent: Thursday, October 20, 2005 2:41
PM
Subject: Re: Applications in
Medicine
Tom Staiger wrote:
I
would agree that an optimal system would benefit from a redesign around a
new paradigm. FYI, similar concerns to yours have been expressed by
Don Berwick, head of the Institute for Healthcare Improvement, an
organization that has been quite influential in trying to promote quality
improvement in healthcare. Dr. Berwick was one of the contributing
authors to "Crossing the Quality Chasm" an Institute of Medicine
publication that followed "To Err is Human" a publication which received
lots of attention in the public and healthcare press with regard to its
estimates of deaths due to medical errors.
Wow! A whole bunch of
questions arose over this post of yours... One is; "How did he arrive at his
estimates for the # of deaths due to medical errors???" I have a hunch that
those numbers are just the tip of the iceberg. To tell you the truth, I think
my father's death was one of those-- but it certainly isn't recorded as one.
Cause of death is listed as "natural causes; end-stage diabetes".
It's
quite true that he was an "end-stage diabetic" whose kidneys had already
failed. However, there were two huge causative factors that in my view were
directly involved in causing his death and both were generated by medical
"care". The first was that his internist (who was new and she didn't know him
that well yet) put him on Prozac for depression but she didn't follow up. He
started developing what I called "Parkinson's Syndrome"-- it looked like
Parkinson's Disease but it came on suddenly with a tremor in one hand a few
weeks after beginning the Prozac, slowly worsening over the next few weeks
until he was physically incapacitated-- couldn't walk even with a walker and
that put him in the position of requiring medical assistance with his
insulin/blood-sugar regulation... which, I believe, was what ultimately killed
him. I had begun frantically researching Prozac when his muscles suddenly
wouldn't support him at all and I learned that Prozac is known to cause this
side effect in some people-- a fact his doctor apparentlydidn't know-- because
she said the symptoms were "probably the beginning of Parkinson's disease" (a
diagnosis, incidentally, that really depressed the hell out of my father, on
top of everything else he was dealing with-- dialysis and all that). I also
found out that two other members of the extended Rosen family had the exact
same experience with Prozac in years previous-- the first had very dramatic
symptoms that included being wheelchair bound until someone thought to do some
research and get them off the Prozac. The symptoms reversed in a matter of
weeks, disappearing completely once the drug cleared the system. So, I had
just arranged for a doctor's order to get Dad off the Prozac and told him to
"hang in there, Dad..." to see if he had the same response to going off the
drug...
But his insulin situation was an everyday requirement and his
physiology was never what can be called "typical". Every time he was ever in
the hospital and the medical personnel were in charge of his blood sugar
management, they always, without exception, put him in a coma. It never
failed. It was always caught early enough to be reversed and then they would
listen to him/me when we tried to describe why they had to deviate from
textbook protocols when managing his diabetes. Well, in this case, it was only
a couple of days that he was not able to do his own insulin shots and he
didn't make it through the second night. They found him in the morning. He had
an emergency button thing on a cord as a necklace, but if he woke up in the
midst of an insulin reaction, he decided not to call for help. I can see that
as a distinct possibility; He was very, very unhappy with his health
situation, and the spectre of being wheelchair-bound (which would necessitate
a move to a nursing home on top of everything) was probably enough to make him
embrace the prospect of a lethal coma. That's if he woke up at all. It's more
probable he died in his sleep. I didn't realize he wasn't doing his own
insulin until a few days after he died, and I had arranged the cremation
already-- it was too late by then. To be honest, I didn't really have the
heart to launch an investigation or prosecute even if I'd known. And it would
have been very hard to prove malpractice if it was possible at all. I was also
5 months pregnant with my third (and we already knew there was something
significant going/gone wrong in the pregnancy) so I was scattered, I was
grieving, and I was trying to hold myself and my family together. Those were
some very hard times.
In any case, I am sure that situations like this
are rampant and the numbers of known or suspected accidental, medically-caused
deaths are vastly underreported.
Tom S. wrote:
One of
the recommendations in "Crossing..." is that "purchasers, health care
organizations, clinicians, and patients should work together to redesign
healthcare processes in accordance with the following rules:
1.
Care based on continuous healing relationships
2.
Customization based on patient needs and values
3.
Patient as the source of
control
4.
Shared knowledge and free flow of information
5.
Evidenced-based
decisions
6.
Safety as a system
property
7.
The need for
tranparency
8.
Anticipation of
needs
These are really fabulous. I was
very pleasantly surprised by such a comprehensive list, especially the fact
that it was generated by a Physician who is very well-versed in modern medical
care, etc. What a nice, hopeful sign! You made my
day!
Judith
Web address:
http://www.rosen-enterprises.com
BioTheory: An electronic journal of
general science based on the Relational (Rosennean) Complexity Paradigm
On Oct 20, 2005, at 1:42 PM, Tom Staiger wrote:
|