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Medical errors are still killing patients in the U.S, let's talk about it

January 18, 2021
Risk Management

“Right now, cancer and heart disease get a ton of attention, but since medical errors don't appear on the list, the problem doesn't get the funding and attention it deserves," said Martin Makary, professor of surgery at the Johns Hopkins University School of Medicine, in an interview with JHU Hub.

It’s fair to say though the tides are beginning to turn, with the science of safety becoming a prominent issue of concern since the turn of the century. The more our technology and expertise matures, the more medical analysts can delve into variables and patterns that were previously obscured. Research analysis has become much more immersed in discovering causation by looking deeper into how communication breakdowns, diagnostic errors, simple poor judgement, and inadequate level of qualifications can directly result in patient harm or death.

It is quite the departure from certain early 20th century directives, which lacked many of the tools and knowledge at our disposal today.

For instance, authoritative nursing texts from the early 20th century reassured medical professionals that passage of a nasogastric tube into the trachea was unlikely and, if it did happen, a sudden “stop” would alert the clinician.

Those texts proved overly reassuring.

These tubes were often malpositioned, leading to significant harm and even death. Further research suggests it existed as a significant contributor to preventable deaths in ICU patients. as Avery L. Smith et al. note in a Baylor University Medical Center study, "This assumption of safety from life-threatening injury is so widely accepted that blind insertion of feeding tubes is routinely performed by nurses who are not required to obtain specific certification for this procedure."

While it’s easy to highlight the role played by physicians who may well have implemented certain unrefined methods throughout their doctorship, the onus should remain fixed on the insufficiencies of the system in which they have operated. The qualifications of doctors are not necessarily in dispute, it’s the conventional framework from which they operate that has neglected certain procedural points of concern.

Doctors are trained to treat the patients, not refine and analyze conventional treatment methods. It’s these conventionally-accepted treatment methods, some of which have remained divorced from modern analytical foresight, that need a renewed focus most. Without this, the system will continue to suffer from poorly coordinated care, fragmented insurance networks, the absence of safety nets, and unwarranted variations in physician practice patterns that lack accountability.

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