Uh-Oh
Mike Abrams, Executive Vice President of the Iowa Medical Society
How many of the words can you read on this physician's note?
Don't cheat - Mouse here to reveal answer!
It seems that, at least monthly, there is another high-profile "uh-oh" in medicine. And the public, government, and payers have an increasingly short fuse when it comes to such incidents. Surely they've been around since the time of Aesculepius, but medical errors seem to be taking center stage more now than ever. Dennis Quaid's twins, wrong-side amputation in Florida, and wrong-side surgery at Duke become office talk. Did you ever think the term "never event" would be a part of medical nomenclature?
So the question is not whether human beings can be made infallible, but can we build systems that acknowledge that human beings are not infallible? Sometimes, when you hear of the cascade of events that lead to medical error, you marvel at how the system was able to chug along for so long without error.
The discipline of patient safety and health care quality has some wonderful evangelists in Iowa. Dr. Tom Evans, Dr. Tim Gutshall, Dr. Dave Sweiskowski and others spend a lot of time contemplating improvements in the way things are done. How can we make it easy for the correct thing to happen, and difficult for mistakes to happen? Too often, the way we do things tend to encourage, rather than dissuade errors.
On the prescription pad above, you should have read the following:
Pregnant
positive
Heparin 1,000 U
Hypotension
hepatitis
The nurse who actually interpreted the pad read 10,000 instead of 1,000 U.
Uh-oh.
