Medical errors are lthe Lord Voldemort of the medical world - "he who must not be named" [1]. And that is the problem. Everyone acknowledges that the dark lord exists, that the lord does terrible things, but who he is, how to find him, and how to stop him, this no one knows. Of course in the novel, Professor Dumbledore knew all the answers and guided his pupil Harry Potter and his team to defeat the terrible Lord Voldemort, but in real life, we simply do not know the answers to these questions. And this ignorance strengthens the power of the dark lord - the power of fear.
Who is Lord Voldemort? This is the fundamental question - what constitutes a medical error? Its ramifications are wide, very wide. They include and are not limited to administration, materials and manpower. So we may end up talking about employment policies, adequacy of equipment, and adverse effects of prescribed drugs.
How to find Lord Voldemort? This will be the next challenge. This includes where to find him and what tools to use. Again the implications are immense. To include or not out patient clinics, emergency response teams, school nurses, hospitals and so on. Whether to use human based data gathering or electronic medical records? What will be the reliability of whatever information is generated?
How to stop Lord Voldemort? This is the most difficult of all. Where will the buck stop? David and Goliath happens in stories or gospel, but not in the world that you and I live in. It is the norm to find scapegoats. What will the medical worker do against the might of medical administration? Legal protection or lack thereof is just one election away. It is likely that sooner or later medical errors will be linked to physician payments, according to a 'system' defined medical 'error'.
To my mind, the solution to these problems lies in the first question - define what is medical error. Clearly, unambiguously, exclusively, and honestly. A tall task, to begin with...
Rapid Response:
Pandora's box has been opened!
Medical errors are lthe Lord Voldemort of the medical world - "he who must not be named" [1]. And that is the problem. Everyone acknowledges that the dark lord exists, that the lord does terrible things, but who he is, how to find him, and how to stop him, this no one knows. Of course in the novel, Professor Dumbledore knew all the answers and guided his pupil Harry Potter and his team to defeat the terrible Lord Voldemort, but in real life, we simply do not know the answers to these questions. And this ignorance strengthens the power of the dark lord - the power of fear.
Who is Lord Voldemort? This is the fundamental question - what constitutes a medical error? Its ramifications are wide, very wide. They include and are not limited to administration, materials and manpower. So we may end up talking about employment policies, adequacy of equipment, and adverse effects of prescribed drugs.
How to find Lord Voldemort? This will be the next challenge. This includes where to find him and what tools to use. Again the implications are immense. To include or not out patient clinics, emergency response teams, school nurses, hospitals and so on. Whether to use human based data gathering or electronic medical records? What will be the reliability of whatever information is generated?
How to stop Lord Voldemort? This is the most difficult of all. Where will the buck stop? David and Goliath happens in stories or gospel, but not in the world that you and I live in. It is the norm to find scapegoats. What will the medical worker do against the might of medical administration? Legal protection or lack thereof is just one election away. It is likely that sooner or later medical errors will be linked to physician payments, according to a 'system' defined medical 'error'.
To my mind, the solution to these problems lies in the first question - define what is medical error. Clearly, unambiguously, exclusively, and honestly. A tall task, to begin with...
References:
1. Harry Potter and the Philosopher's Stone. Available at: https://en.wikiquote.org/wiki/Harry_Potter_and_the_Philosopher%27s_Stone
Competing interests: No competing interests