Risk Management

[militarymd]

I just got home from a risk management seminar which will save me 10% on my malpractice coverage.

THE SPEAKERS WERE SPEWING SO MUCH CRAP, I THOUGHT THEY MUST HAVE SOME KIND OF GI OBSTRUCTION.

They weren't saying anything new.....just the same stuff that I have never agreed with.

1) when something bad happens, it is not the individual's fault. It is the system's fault.

2) we should not try to find the person at fault. we need to change the system

What a load of crap!!! When something goes wrong, you can ALWAYS find the person at fault....I think we need to identify the person, blame the person, and shame that person...so that person can learn from the mistake....including myself.

The speakers were blaming everything from the surgeon to the hospital administration for errors like giving the wrong drug.

It is the person's fault.

Let's hear everyone's opinion on this one.

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[toughlife]

Sounds like the typical society's mentality of never fessing up to its mistakes. Easier to blame everyone else instead of ourselves.

 

[MDEntropy]

I am uncertain as to why you started this thread. What I mean by this is that I don't know if you want to hear other's opinions because you want to open your mind or you just want to argue. I suspect the latter given the tone of your post. Yet, I will bite. Sort of. I don't want to argue but I don't want you to mislead the masses of young minds reading this forum with your simpleton approach. I must say, although I shouldn't be surprised by your opinions, I often am. You seem to have fairly sophisticated analyses/responses to purely medical issues/questions when they are technical in nature, but when it comes to organizational behavior and dynamics not only does the sophistication go out the window, you exhibit obstinance that often overlooks even common sense.

While you and your regular posting buddy JPP often claim to be in accord, I must say that his approach to systems while often based in common sense, has always seems far more matured. And while I wish I could see debates between the two of you escalate at points of disagreement, this just doesn't seem to happen. I speculate on why this is the case, but won't go into that now.

As for your OP, I will point to some of the work by Gaba and colleagues at Stanford on crisis resource management. Although much of the text they have written is focused on specific events, the intial chapters look more at how (and thereby why) adverse events take place.

Human error is a component of most adverse events, but usually this is not due to intention or gross negilgence. So then why do bad things happen - are people just stupid or lazy? And if so, then do bad things happen more often in community hospitals in huntsville than they do in the ivory towers of the longwood medical area?

If we let our commercial pilots fly 150 hours a month, there may be more plane crashes and we can pinpoint why each individual joe blow had an accident, and if he survived, we can even 'shame' him. But if we instead limit his hours along with those of his colleagues we will be much more effective and safe.

Systems changes can help reduce many of the human errors that lead to bad outcomes more effectively than finger pointing and ridiculing. Sadly, anesthesia education is generally lacking when it to comes to global prevention of errors and management of crises.

As an aside, it seems that more and more academic centers are introducing anesthesia simulator based training pioneered by Gaba and company based on concepts from the aviation industry (as is much of their work). Still, the way the simulators are used may or may not lead to education re: systems changes to reduce errors - although use of a simulator may BE a system change that leads to human error reduction in practice.

 

[militarymd]

I knew you lurk..mdent.

I'm still waiting to hear about your management experience, level of training, etc.

 

[militarymd]

Gaba was the speaker....and he's a fool.


He compared anesthesia safety issues to aviation safety issues. Such comparisons are only valid when certain underlying assumptions/rules are the same.

In aviation simulators...if you fail, you don't go on your merry way and keep doing whatever you were doing before....like anesthesia simulators...you kill the dummy, the next day you're back doing anesthesia.

Do you know how many F-14 hopefuls wash out??? I don' know the exact numbers, but I'll tell you it is orders of magnitude higher than the number of medical students and residents who washout.....

So for the Simulator to be effective in improving safety, people who fail need to stop doing anesthesia....that is not the case. Gaba himself said there is no data to support that "systems" improve safety.....but if it works for the aviation industry.....Yea...that's a good comparison.

"Systems" may help decrease errors. "Systems" may make it easier to avoid errors, but the ULTIMATE source of the error IS the individual.

If one CANNOT handle working more than 24 hours at a time, then that INDIVIDUAL needs to stop working at the 24 hour mark.

If you screw....YOU screw up....not the surgeon, not the hospital, not the "system"

 

[The_Sensei]

If you screw....YOU screw up....not the surgeon, not the hospital, not the "system"

I must agree with you on this one. As a professional, as a physician, and as a man, you MUST be accountable for your actions. Everyone makes mistakes, but ours have much more dire consequences. The public views physicians as infallible. Whether or not this is justified is a moot point; the point is that for any patient, nothing other than perfection is tolerated.

We had some bullsh*t lecture about failures being a systems based phenomenom during residency. I thought it was the most non-sensical cop-out lecture I have ever heard. C'mon, gang....if you screw up, it's your own damn fault. Don't come crying to me about fatigue or your dog having diarrhea because I don't care. Step up and accept responsibility or step out!

 

[The_Sensei]

If you screw....YOU screw up....not the surgeon, not the hospital, not the "system"

I must agree with you on this one. As a professional, as a physician, and as a man, you MUST be accountable for your actions. Everyone makes mistakes, but ours have much more dire consequences. The public views physicians as infallible. Whether or not this is justified is a moot point; the point is that for any patient, nothing other than perfection is tolerated.

We had some bullsh*t lecture about failures being a systems based phenomenom during residency. I thought it was the most non-sensical cop-out lecture I have ever heard. C'mon, gang....if you screw up, it's your own damn fault. Don't come crying to me about fatigue or your dog having diarrhea because I don't care. Step up and accept responsibility or step out!

 

[VentdependenT]

He compared anesthesia safety issues to aviation safety issues. Such comparisons are only valid when certain underlying assumptions/rules are the same.

In aviation simulators...if you fail, you don't go on your merry way and keep doing whatever you were doing before....like anesthesia simulators...you kill the dummy, the next day you're back doing anesthesia.

Do you know how many F-14 hopefuls wash out??? I don' know the exact numbers, but I'll tell you it is orders of magnitude higher than the number of medical students and residents who washout.....

So for the Simulator to be effective in improving safety, people who fail need to stop doing anesthesia....that is not the case. Gaba himself said there is no data to support that "systems" improve safety.....but if it works for the aviation industry.....Yea...that's a good comparison.

"Systems" may help decrease errors. "Systems" may make it easier to avoid errors, but the ULTIMATE source of the error IS the individual.

If one CANNOT handle working more than 24 hours at a time, then that INDIVIDUAL needs to stop working at the 24 hour mark.

If you screw....YOU screw up....not the surgeon, not the hospital, not the "system"

 

[fishtolive]

OR doesn't have a system assuring sterility of a certain agent (e.g., everybody gets a swig of thio from the pot)--system failure.

every other f up you cause (e.g., deliver the wrong agent, malpositioning, poor management of crises, etc.)--personal failure.

the system at fault in the latter case is your own central nervous system.

this crap is like the sensitivity/cultural diversity classes they throw on us regularly in medical school--if you are a racist, sexist bastard then no half day course is gonna help or change you. likewise, if you aren't attentive in the OR to the simplest of details (labeling syringes comes to mind) then no systems failure course is gonna help you.

 

[MDEntropy]

Usually bad outcomes are due to the operator not the machinery. But the question is "why" did the individual make the mistake? Is it because they weren't worried enough that mmd or his colleague concrete-thinking-md would come 'shame' them? Of course not. Maybe they are lazy or stupid, but usually that's not it either. So why the mistake?

There are plenty of data showing that system based changes improve outcomes.(i.e blood banks, or something more up your alley - protocols for vent weaning leads to less vent days than intensivists looking at patient and the data and making a decision - you may want to argue the details but that is why big time medical centers put these protocols in place). Its semantics you want to try to argue the difference between outcomes and safety. Rare errors will always be hard to study because it will be tough to get the power to show a difference, but the outcome data is everywhere.

By the way, real pilots use flight simulators. And when they make an error, they don't give up their career.

"[Gaba]'s a fool" - ok, and I guess you are the expert instead. Only on SDN. Which might explain why you post here so much. But doesn't explain why Gaba comes to talk to you.

 

[MDEntropy]

I knew you lurk..mdent.

I'm still waiting to hear about your management experience, level of training, etc.

While these factors may shape my posts, it doesn't color how you read them.
Aah, but it might.

 

[MDEntropy]

E-case, middle of the night.

20 seconds into RSI surgeon walks in to the room and yells at the nurse to do something 'now'. Nurse then releases cricoid pressure. Within seconds the pt. cleary aspirates. Technically, the surgery goes well but days later the pt., who was unable to be extubated at the end of the procedure, dies of severe PNA and resulting overwhelming sepsis.

I suppose all who have posted thus far would blame/shame the anesthesiologist.

 

[militarymd]

Usually bad outcomes are due to the operator not the machinery. But the question is "why" did the individual make the mistake? Is it because they weren't worried enough that mmd or his colleague concrete-thinking-md would come 'shame' them? Of course not. Maybe they are lazy or stupid, but usually that's not it either. So why the mistake?

Why does an individual make a mistake? Simple, they either didn't know any better or they weren't paying attention, or they made an error in judgement....errors in judgement is where experience comes from...hence I'm asking yours....seems you have little...otherwise you would tell us. I have a colleague who ordered gentamicin for a total knee yesterday because the patient had an prosthetic aortic valve. He made an error....why??? because he never read the 1997 AHA guidelines because he is lazy and doesn't read.

There are plenty of data showing that system based changes improve outcomes.(i.e blood banks, or something more up your alley - protocols for vent weaning leads to less vent days than intensivists looking at patient and the data and making a decision - you may want to argue the details but that is why big time medical centers put these protocols in place). Its semantics you want to try to argue the difference between outcomes and safety. Rare errors will always be hard to study because it will be tough to get the power to show a difference, but the outcome data is everywhere.

The data supports having trained "individuals" taking care of these patients.

By the way, real pilots use flight simulators. And when they make an error, they don't give up their career.

I was in the Navy for 11 years, I know plenty of real pilots...and FIGHTER pilots at that. If they fail the simulator, they don't fly....doctors can fail simulators, they still practice...hell there are plenty who don't even pass their boards and they practice.

"[Gaba]'s a fool" - ok, and I guess you are the expert instead. Only on SDN. Which might explain why you post here so much. But doesn't explain why Gaba comes to talk to you.

I spoke with the man. I assessed his OPINIONs. I asked a few questions. My assessment is he is a fool and now I'm telling my internet friends.

He paid me about a thousand dollars to go listen to him, so who's the fool.

 

[MDEntropy]

Many licensed pilots choose to use simulators to improve their skills.

The use of protocols assumes 'trained' individuals. I am not sure what you are getting at, but obviously without individuals you have no system, but key change can be implemented at a system level to change individual behavior.

Gaba didn't pay you a penny (you asked , "who's the fool?"). You may receive an insurance discount, but he is not paying it. Essentially, insurance companies are willing to give up millions in revenue just so you will listen to this "fool" talk.

 

[militarymd]

Gaba didn't pay you a penny (you asked , "who's the fool?"). You may receive an insurance discount, but he is not paying it. Essentially, insurance companies are willing to give up millions in revenue just so you will listen to this "fool" talk.

I guess the insurance company is the fool here....got fooled into thinking that "system"s cause malpractice, and not the individual.

 

[militarymd]

I knew you lurk..mdent.

I'm still waiting to hear about your management experience, level of training, etc.

Come on..entropy.let's hear about your management experience, level of training, experience with "systems"

Come on...everyone else here has no problems with who they are....you're the only one hiding behind your internet name.

 

[gaspasser2004]

Ultimately, as a physician, you are responsible for whatever mistakes you might make, but the systems based approach can prevent bad outcomes from happening in the first place.

For instance, before each day of cases, we all check out the anesthesia machine in a systematic way, checking for presence of back-up oxygen, resuscitation equipment, etc. ASA monitors are a systematic way of detecting problems pre-op, intra-op and post-op. My institution is always looking for ways to bundle supplies to reduce error. In our outpatient eye center, the only vaporizers are desflurane and sevoflurane so that no one has the chance to give a patient iso that might give a long wake up/long time in PACU.

I have also developed some of my own "personal" systems to avoid mistakes. For instance, if I know my next patient is penicillin-allergic, I actively hide the ancef (even though I need it later in the day for another patient) so I don't even have the opportunity to give it to the allergic patient. Likewise, when drawing up dangerous meds like heparin or insulin, I only draw up exactly what I need instead of a big syringe to lay out on the cart. These may sound like small, obvious common sense steps, but you would be surprised what a CA-1 is capable of when things get crazy...

As a physician, my mistakes are my own, but I can actively reduce the chance of me making a mistake by having a sound systematic approach to safety. Just my thoughts...

 

[MDEntropy]

Come on..entropy.let's hear about your management experience, level of training, experience with "systems"

Come on...everyone else here has no problems with who they are....you're the only one hiding behind your internet name.

Stop worrying about me and focus on my e-case.

 

[militarymd]

Stop worrying about me and focus on my e-case.

EVERYONE is at fault. The anesthesiologist bears the responsibility, and the lawyer will go after the one with the deepest pocket.


Your posts have all the essence of a pseudo-intellect. You must have finished high school...maybe even college.

But you clearly have no real-world experience......yet you believe you know it all...and take much offense at anything that is not politically correct.....

Trust fund baby with a lot of free time???

No doubt a Democrat...

 

[MDEntropy]

I am the pseudo-intellect. Riiiiiiiiight.

As for the case, unfortunately for you mmd, based on what you have previously said, your answer can't be right. You just blamed the system with..."Everyone is at fault". What happened to "When something goes wrong, you can ALWAYS find the person at fault."? Now, all of a sudden, there are miltiple people at fault in one incident. In fact, you say that "everyone is at fault".

With my case, I didn't make the argument that everyone is fault and that the system is the problem. In fact, I could make some arguments that a specific individual is fault here. But you MMD, now have some explaining to do...

Really, regardless of what you now try to spin, when something bad happens you can't always find THE person at fault, as you just illustrated with my example. Thanks. Sometimes there is a person at fault, but they aren't lazy or stupid.

By the way, if you consider your colleague lazy, why work with him?

Chime in vent. And dare I challenge you to read more by Gaba (he has a couple of chapter's in miller) before giving thumbs up to a post subtitled "Gaba is a fool". I am not trying to attack you by any means, and who knows maybe you have read a lot of his articles and stuff already. I just want to challenge you to think broadly as a budding anesthesiologist trying to be all you can be, and avoid getting overwhelmed with simple dogma.

 

[militarymd]

I see you have bought into the "root" cause frame of mind....Root Cause Analysis type BS that is all the trend where you try to identify the "root cause" in the system that causes the error/poor outcome.

That is the reason why when I said "individuals" are at fault, you assume that only ONE individual can be at fault in an event with a poor outcome.

Your silly case shows an example of where 3 different people committed errors. Each of those people needed to have accountability for their own actions.

MDent, you, my little friend, have been brainwashed into relinquishing your own accountability for your actions....go through your life thinking that it's not your fault....."it's the system's fault"...that's going to work real well at your deposition.

 

[MDEntropy]

I quoted you directly in my previous post.

"When something goes wrong, you can ALWAYS find the person at fault"

"It is the person's fault."

This has now somehow miraculously been transformed to - finding the numerous individual at fault for even a single error, or the group of people at fault, even it if is everyone in the room.

I guess the specific concept of a system is too abstract. But thanks again, I think you often help clarify things for others, even though it's not your intention.

Bad systems don't force people to make mistakes, but good systems help protect people from making mistakes. Everyone makes mistakes but ceteris paribus those in the better system will make fewer errors.

I must agree, that from the individual perspective, it is dangerous to get into a habit of blaming the system. On the other hand, to ignore the role of the system in magnifying or reducing the likelihood of error is similary dangerous, particularly if you play a role in creating or managing the system.

 

[Noyac]

This is a serious question b/c I would like to know how a system will prevent someone from giving the wrong syringe. I ask b/c we had a locums person give a stick of nondepolarizer vs. a depolarizer. The person thought they gave Sux but it wasn't. How does a system prevent this without being a hindrance to efficiency? I'm a little confused. The system of drawing up drugs mentioned above by gaspasser is nothing more than a personal system.
I'm not convinced by either of you two. I believe there are personal deficiencies as well as system deficiencies. A great system can still be thwarted by a bozo and a great practitioner can be thwarted by a crappy system.

 

[zippy2u]

Military, Next time tell your insurance co. to send you the CME 10% reduction questions in the mail and you just fill them out in your home and send them back in. I'd never travel anywhere other than my own home to deal with all that garbage. Reminds me of the time when GWB gave me my tax rebate of $100. Ya pay $80,000/year in taxes and the mofo gives me back $100. I felt like wipin' my arse and mailing it back to him but didn't want the Secret Service and FBI at my door. Regards, ----Zippy

 

[aredoubleyou]

This is a serious question b/c I would like to know how a system will prevent someone from giving the wrong syringe. I ask b/c we had a locums person give a stick of nondepolarizer vs. a depolarizer. The person thought they gave Sux but it wasn't. How does a system prevent this without being a hindrance to efficiency? I'm a little confused. The system of drawing up drugs mentioned above by gaspasser is nothing more than a personal system.
I'm not convinced by either of you two. I believe there are personal deficiencies as well as system deficiencies. A great system can still be thwarted by a bozo and a great practitioner can be thwarted by a crappy system.

Couldn't have been said better

 

[bullard]

First of all, Military, much respect to you -- I've learned a lot from your posts.

But I think your reasoning here is a bit flawed. Take this example.

Say you've got a resident admitting a patient in ARDS to the ICU at 2 am. He writes the orders and botches the vent orders, writing for 12 mL/kg tidal volumes instead of 6 mL/kg.

It seems like in your world, the next day, you make your rounds and bitch out the resident for forgetting about the ARDSnet 2000 study, and everybody "learns" from it. Good luck hearing about mistakes in an environment like that.

In MDEntropy's world, you'd have an ARDS order sheet (if this hospital is doing the paper thing) which would include a low tidal volume protocol and whatever other interventions are specific to ARDS. This is the systems approach.

I dunno, I like the second way better.

 

[militarymd]

I quoted you directly in my previous post.

"When something goes wrong, you can ALWAYS find the person at fault"

"It is the person's fault."

This has now somehow miraculously been transformed to - finding the numerous individual at fault for even a single error, or the group of people at fault, even it if is everyone in the room.

I guess the specific concept of a system is too abstract. But thanks again, I think you often help clarify things for others, even though it's not your intention.

Bad systems don't force people to make mistakes, but good systems help protect people from making mistakes. Everyone makes mistakes but ceteris paribus those in the better system will make fewer errors.

I must agree, that from the individual perspective, it is dangerous to get into a habit of blaming the system. On the other hand, to ignore the role of the system in magnifying or reducing the likelihood of error is similary dangerous, particularly if you play a role in creating or managing the system.

Pick any one of the three. It doesn't matter. An "individual" was at fault. It just so happens that 3 "individuals" are at fault.

You are obviously a youngster who believe that personal responsibility is not a desirable trait.

To you, it is better to rely on a "system" rather than yourself.

Blame the system, not yourself....It's not "my" fault that "I" lost someone's airway....it is the "system"'s fault.....

It works real well in a court of law.

As long as you can sleep peacefully at night...that's all that matters.

 

[militarymd]

First of all, Military, much respect to you -- I've learned a lot from your posts.

But I think your reasoning here is a bit flawed. Take this example.

Say you've got a resident admitting a patient in ARDS to the ICU at 2 am. He writes the orders and botches the vent orders, writing for 12 mL/kg tidal volumes instead of 6 mL/kg.

It seems like in your world, the next day, you make your rounds and bitch out the resident for forgetting about the ARDSnet 2000 study, and everybody "learns" from it. Good luck hearing about mistakes in an environment like that.

In MDEntropy's world, you'd have an ARDS order sheet (if this hospital is doing the paper thing) which would include a low tidal volume protocol and whatever other interventions are specific to ARDS. This is the systems approach.

I dunno, I like the second way better.

So when is the resident supposed to learn anything......Just rely on pre-printed orders....

Who is supposed to come up with the orders?

Who dx the patients? Is it really ARDS and not something else?

"systems"/"Protocols" exist to assist the individual.....however, the physician is always ultimately responsible.

You want to give up that responsibility? Well, then you might as well be a CRNA.

 

[sdn1977]

Respectfully, I would add it is sometimes a "shared" responsibility. Yes...the anesthesiologist always, ultimately has the responsibility for what he/she did inject parenterally or allow to be inhaled. However, I have been aware of cases of "mixed-up" prefilled syringes, either drawn up by an AA tech or the OR pharmacy or premixed bags being mislabeled or misread - all very bad mistakes and not the responsibility for the one administering except that that person did, so they take on the responsibliity, albeit shared with that person who drew it up or mixed it up - thus a system error. (On a side note...I have had the very misfortune of having to "count" narcotics & refill anesthesia trays with already drawn up & unlabeled syringes for the next day - who would know if anyone had inadvertantly mixed them up, not that anyone did, but...???). I would put forth we all accept the responsibility of our own mistakes, but the system might be a factor in why the mistake took place (ie if you were in a position to draw up all your own syringes or not - some don't have that option).

 

[nitecap]

Why cant you guys just meet halfway and propose protocols that when not follwed people are held accoutable unless its a valid reason. Off course people should be held accoutable at some point but first the problem must be investigated to see what the hell went wrong. Many problems are d/t poor comunication b/t professionals or departments. In these cases holding one person accountable is useless while developing protocols and better systems may be more effective in preventing future issues.

For instance in a pyxis robinol and metaclopramide are right next to each other. They are both in the same size vile. They both had green printed labels. They are in the same drawer side by side compartments. Pts puking in ICU after extubation nurse running for reglan grabs glyco hurrying doesnt double check pushes glyco and in 2 minutes we are pushing atropine, epi and doing compressions. Who is at fault? The way administration and risk mgmt saw RN for not double checking and following scope of practice, pharmacy for putting 2 meds with so similar looking viles (msp) so close together. RN had to take extra pharm class, pharmacy had to totally rework all med administration pyxises in the hospital. Both were held accountable. The RN hopefuly wil not make another error, the pharm saw how the placement may make an error easier.

Seeing it one way is just plain narrow minded. Holding someone accountable while at the same time investigating and forming strategies to prevent future errors would be more effective.

If hlth care would take the approaches of either mmd or entropy we would be alot worse off.

Entropy if we always blamed the system than peeps wouldnt have any reason to be vigilant. Who would care if they screwed up if there was no action on you personally. I think many times the threat of law suits, loss of jobs, discipline by the profession makes people think twice when they get that feeling of doing something halfass.

MMD if we took your route then no one would ever develop any systems, protocols or techniques all which make things safer and more efficient. It is these type of systems that prevent error that will help to make your malpractice go down in your area.

 

[davvid2700]

Why cant you guys just meet halfway and propose protocols that when not follwed people are held accoutable unless its a valid reason. Off course people should be held accoutable at some point but first the problem must be investigated to see what the hell went wrong. Many problems are d/t poor comunication b/t professionals or departments. In these cases holding one person accountable is useless while developing protocols and better systems may be more effective in preventing future issues.

For instance in a pyxis robinol and metaclopramide are right next to each other. They are both in the same size vile. They both had green printed labels. They are in the same drawer side by side compartments. Pts puking in ICU after extubation nurse running for reglan grabs glyco hurrying doesnt double check pushes glyco and in 2 minutes we are pushing atropine, epi and doing compressions. Who is at fault? The way administration and risk mgmt saw RN for not double checking and following scope of practice, pharmacy for putting 2 meds with so similar looking viles (msp) so close together. RN had to take extra pharm class, pharmacy had to totally rework all med administration pyxises in the hospital. Both were held accountable. The RN hopefuly wil not make another error, the pharm saw how the placement may make an error easier.

Seeing it one way is just plain narrow minded. Holding someone accountable while at the same time investigating and forming strategies to prevent future errors would be more effective.

If hlth care would take the approaches of either mmd or entropy we would be alot worse off.

Entropy if we always blamed the system than peeps wouldnt have any reason to be vigilant. Who would care if they screwed up if there was no action on you personally. I think many times the threat of law suits, loss of jobs, discipline by the profession makes people think twice when they get that feeling of doing something halfass.

MMD if we took your route then no one would ever develop any systems, protocols or techniques all which make things safer and more efficient. It is these type of systems that prevent error that will help to make your malpractice go down in your area.

hey nitecap

why dont you go to nursing forum.. you are not welcome here. you consistently post anti md propaganda here. SO why are you still here? go to the nursing forum.

 

[nitecap]

hey nitecap

why dont you go to nursing forum.. you are not welcome here. you consistently post anti md propaganda here. SO why are you still here? go to the nursing forum.

Why talk trash man? Was my previous post at all negative. I have spoken to some forum posters here via PM and have agreed to chill at the moment. This overall has been a pretty constructive thread despite the difference of opinions, why try to make it negative ole davo .why take aways its mojo.

Look PM me if you want to meet in a chatroom or yahoo messenger and we can get down all damn night. We all know what happened last time not sure if you want to go there. Lets keep it clean here though man. This post/thread should not turn into a them against us war, its useless here man. Plus we screw up this thread. So dave chill man, like I said message me and we can roll up the sleeves and get ruthless if you are dying for a aurgument, but else where. If not just step down dave. Or as we but it in Htown, boot up or shut up.

AS well dave I have been here way longer than you, and will be here longer so accept that for what it is.

 

[MDEntropy]

Haven't read all the new posts, yet but after reading a couple, I want to make a couple of quick points.

I try not to see the world in black and white. We have Mmd to do that. Thus, because I disagree with his very one sided view, he will try to cast me as believing the complete opposite of what he does, while he fires off insults with every other line and then calls me childish. It seems to work though, thus Noyac's statement about believing in both personal and system deficiencies as if mmd believes in one and i believe in the other. I believe the same thing as noyac. And I have said that. But Mmd would have you believe that I don't think people even make mistakes. The borderline, splitting, dichotomous approach just isn't for me

Individuals have the overwhelming majority, if not all of the accountability. Systems can help prevent individuals from making some mistakes, but not all. Thus, there is value in paying attention to your systems and designing and re-designing them to help protect the individual from error and ultimately the patient from suffering.

 

[MDEntropy]

Entropy if we always blamed the system than peeps wouldnt have any reason to be vigilant. Who would care if they screwed up if there was no action on you personally. I think many times the threat of law suits, loss of jobs, discipline by the profession makes people think twice when they get that feeling of doing something halfass.

Look, your post really bothers me. When did I say always blame the system? Please go back and quote me on that. Have you read Gaba? Clearly not. His work says nothing about always blaming the system. Please don't address me about statements that I never made and read MY posts, not someone elses if you are going to comment on MY opinion.


I mean lets get real here. Everyone wants to talk about meeting somewhere between my opinion and mmd's but I am not way out there on the other end of the spectrum as MMD would have you believe. He does this splitting thing every single time he debates with someone and people always fall into his traps. It's nuts. Read what I wrote, then address what I have said, if you would like to talk to me about my opinions. And when you do that I am happy to respond to and discuss the content of your posts.

 

[militarymd]

while he fires off insults with every other line and then calls me childish.

I believe it first started when you directed insutlts against me. It is only appropriate that I return them.

Your very first post you called me a simpleton who is obstinant and lacks maturity......I guess those aren't insults?

 

[davvid2700]

Why talk trash man? Was my previous post at all negative. I have spoken to some forum posters here via PM and have agreed to chill at the moment. This overall has been a pretty constructive thread despite the difference of opinions, why try to make it negative ole davo .why take aways its mojo.

Look PM me if you want to meet in a chatroom or yahoo messenger and we can get down all damn night. We all know what happened last time not sure if you want to go there. Lets keep it clean here though man. This post/thread should not turn into a them against us war, its useless here man. Plus we screw up this thread. So dave chill man, like I said message me and we can roll up the sleeves and get ruthless if you are dying for a aurgument, but else where. If not just step down dave. Or as we but it in Htown, boot up or shut up.

AS well dave I have been here way longer than you, and will be here longer so accept that for what it is.

everything you say or do does not have any merit...

If i were supervising you... I would rarely leave your side.. I would want to know every single drug that you are injecting and why.. (for the patients sake) You are a dangerous man.. and I would be well within my practice rights to curb your practice.. I would do all spinals or epidurals.. I would severly limit your practice you cocky nurse..

 

[nitecap]

withdrawn, i said I wouldnt let it get ugly, I'll PM insecure david

 

[MDEntropy]

I believe it first started when you directed insutlts against me. It is only appropriate that I return them.

Your very first post you called me a simpleton who is obstinant and lacks maturity......I guess those aren't insults?

You insult half the people on the forum. This didn't just start with me yesterday.

That said, I would prefer you insult me all day, then knowlingly misquote me and mischaracterize what I have said taking the attitude that if you put words in my mouth, I have the opportunity to come back and correct you.

But I would prefer to get off this subject and just focus on the original issue.
I really don't want this to be about you and me.

 

[bullard]

You're putting words in my mouth. I agree that systems exist to assist the individual but that the doc is ultimately responsible -- that was the point of my post.

So when is the resident supposed to learn anything......Just rely on pre-printed orders....

Who is supposed to come up with the orders?

Who dx the patients? Is it really ARDS and not something else?

"systems"/"Protocols" exist to assist the individual.....however, the physician is always ultimately responsible.

You want to give up that responsibility? Well, then you might as well be a CRNA.

 

[davvid2700]

You're putting words in my mouth. I agree that systems exist to assist the individual but that the doc is ultimately responsible -- that was the point of my post.

by the way guys

nitecap just pmd me and used the nastiest language known to man. He is a nurse always will be he is not man enough to go through the rigors of medical school so he chose the easiest route and he comes on this board thinking its equivalent. You need to leave this board my friend..

 

[Monty Python]

........
If one CANNOT handle working more than 24 hours at a time, then that INDIVIDUAL needs to stop working at the 24 hour mark......

Since you opened that particular can of worms, how do you think this situation is best handled?

You're a group employee at a private hospital. The group policy is to allow the first call person to be off the following day, "circumstances permitting," (which is usually). You're first call that day. You arrive at 0600 that morning for a day of hearts (which is where the first call person is usually assigned). You work essentially non-stop all day with 3 CABGs, with rare breaks. After the last CABG is in the unit around 1900, you then pick up the add-on rooms, with the appy, with the small bowel obstruction, etc.

Finally around 0300 (after you've been there 21 hours) the coast is clear and you head for the door. You're bone-tired. You notice that due to other group members being on scheduled vacation and you're needed back on the schedule the next day, which is all of 3 hours from now.

Looking at this strictly from a safety perspective, akin to work limits on commercial pilots (and overlooking the historical tenets of medicine in general, working through your fatigue) how is this best handled?

 

[militarymd]

You're putting words in my mouth. I agree that systems exist to assist the individual but that the doc is ultimately responsible -- that was the point of my post.

Bullard ,

You're right. The systems may exist to help you, but when mistakes are made, the "individual" makes them.

A poster gave the example of his/her system of labelling and giving drugs. Very nice way of doing it, but then who's fault is it when that person does give the wrong drug?

Focus on the individual. If you have a properly trained and motivated "individual", then it doesn't matter what kind of "system" you have around him for him to make things work.

The people who are focusing on the "system" do so with the underlying assumption that we have properly trained and motivated "individuals" already in the system.....that is simply NOT true.

 

[militarymd]

Since you opened that particular can of worms, how do you think this situation is best handled?

You're a group employee at a private hospital. The group policy is to allow the first call person to be off the following day, "circumstances permitting," (which is usually). You're first call that day. You arrive at 0600 that morning for a day of hearts (which is where the first call person is usually assigned). You work essentially non-stop all day with 3 CABGs, with rare breaks. After the last CABG is in the unit around 1900, you then pick up the add-on rooms, with the appy, with the small bowel obstruction, etc.

Finally around 0300 (after you've been there 21 hours) the coast is clear and you head for the door. You're bone-tired. You notice that due to other group members being on scheduled vacation and you're needed back on the schedule the next day, which is all of 3 hours from now.

Looking at this strictly from a safety perspective, akin to work limits on commercial pilots (and overlooking the historical tenets of medicine in general, working through your fatigue) how is this best handled?

If you feel you can't do something safely, you don't do it. I've done it before.

 

[MDEntropy]

If you have a properly trained and motivated "individual", then it doesn't matter what kind of "system" you have around him for him to make things work.

This is exactly WRONG, which is the whole point. The system does matter assuming properly trained individuals.

You believe the system doesn't matter.

Gaba believes it does matter. This certainly doesn't remove all or even most responsiblity from the individual. But if I put you into a great system, you will make less errors than you do now and that would be a good thing.

 

[militarymd]

This is exactly WRONG, which is the whole point. The system does matter assuming properly trained individuals.

You believe the system doesn't matter.

Gaba believes it does matter. This certainly doesn't remove all or even most responsiblity from the individual. But if I put you into a great system, you will make less errors than you do now and that would be a good thing.

Gaba believes that when an error occurs, the review process needs to NOT identify who is at fault, but rather identify the conditions in the work environment that caused the error/adverse event.

How ELSE can you interpret that other than to relieve the "individual" at fault for the adverse event?

How would any system prevent a surgeon from being an ass....how would any system prevent a nurse from jumping at a surgeon's bark....how would any system help the anesthesiologist give clearer directions to his/her assistant?

People like Gaba, who practice in the ivory towers, and students, like you who have not been in practice, will say....the hospital can have rules for the surgeons where if they misbehave they lose their privileges....easy...new system to prevent surgeons from being an ass.

The surgeon loses his privileges, so he takes his business elsewhere....now no adverse event will occur because there are no cases to do....system has fixed the problem....now you have a new problem....no work...no income.

 

[MDEntropy]

Gaba believes that when an error occurs, the review process needs to NOT identify who is at fault, but rather identify the conditions in the work environment that caused the error/adverse event.

How ELSE can you interpret that other than to relieve the "individual" at fault for the adverse event?

How would any system prevent a surgeon from being an ass....how would any system prevent a nurse from jumping at a surgeon's bark....how would any system help the anesthesiologist give clearer directions to his/her assistant?

People like Gaba, who practice in the ivory towers, and students, like you who have not been in practice, will say....the hospital can have rules for the surgeons where if they misbehave they lose their privileges....easy...new system to prevent surgeons from being an ass.

The surgeon loses his privileges, so he takes his business elsewhere....now no adverse event will occur because there are no cases to do....system has fixed the problem....now you have a new problem....no work...no income.

Every picture you paint is black and white. Every outcome dichotomous. Maybe your world is like this, if so it is in large part because you believe it is like this. Systems don't solve all problems, and often it takes a great deal of thought to allign incentives in a system and make it work.

If you spent half the energy you use misquoting people, mischaracterizing people and putting words in people's mouths (happens in at least half of your posts that are longer than 2 sentences) on something constructive, every other person that comes to work for/with you might not be another "lazy" bum. For some reason, they seem to gravitate toward your practice, and you made it quite clear in a previous debate that this has nothing to do with your management of human resources and methods of selection. Must be the location.

 

[militarymd]

Believe it or not...life is dichotomous.


Every decision you make is dichotomous. A variety of variables may affect your decision, but the decisions are dichotomous.

In my experience, managing 2 sixteen OR suites, a residency educational program, etc....I have found that decisions are dichotomous..

Tell us how your experiences show you how things are NOT dicchotomous....managing an anesthesia group...or what????

 

[sdn1977]

If you feel you can't do something safely, you don't do it. I've done it before.

I hesitate to post here again because I'm afraid to become embroiled in the tension. Hopefully, you will take my reply with all the respect I intend...I can appreciate your distaste for the speaker you were forced to listen to because, perhaps, you can do exactly what you have said & just not do something when you decide you are no longer safe. Those of us who are cogs in the wheel of hospital medicine (I am a pharmacist) do not have that luxury. I have indeed had to restock anesthesia trays & make cardioplegia solutions after my 10 or 12 hour shift was over - why???? because the anesthesiologists & surgeons needed them by 5AM & I was the last pharmacist on until 7AM. The "system" didn't allow me to just leave or I would have caught endless @%&^ starting with my boss, going on from there to the OR supervisor & ending with one of the many hospital administrtors (believe me....I've lived this!)

In this, and many other situations, the "system" was the fault and I did my very best with what I had at the time (isn't there a saying....you never want to be your surgeon's last case - well...that is ever so true with your pharmacist!). I'm very well trained and very cognizant of the many studies documenting how many more mistakes folks like me make under these circumstances. I have always taken full responsibility for every mistake I have made & fortunately, never involved another professional. However, if I screw up your anesthesia tray, we both carry the responsibility...but, you are the deeper pocket! I'd probably be dropped from the suit, even though the source of the error would have been me - I'm not proud of that - it just is what it is. My take is the guy might have been trying to make you more receptive to folks like me - those of us who don't have your freedoms.

As a final note (sorry for the soooo long winded post)...I quit my job of 20 years just for this very reason. I had become the 7AM pharmacist too many times, by myself for 2 hours, handling ALL the ICU overnight orders (nurses cannot access pyxis if the order has not been put in the computer - the "system" again), ALL the OR orders, supervising 4 technicians & dealing with chemo orders whose dosages & labs hadn't been checked. Yeah - finally I decided - I wasn't going to end my career screwing up a chemo order (????for your wife, mother, dad???) because the system was failing me.

Again, very respectfully, I appreciate your sentiments. My intention is not to claim you hold an opinion that does not have validity because all of us do. Just perhaps consider, the guy was giving the same "generic" risk management talk he will deliver to the ASHP (the professional hospital pharmacist organization) this spring & you just got sucked into listening to his spiel? Those of us who listen to that one will have a different persepctive from yours - not better nor worse - just different. Respectfully......

 

[MDEntropy]

Coming up on four years since we had this little discussion. Any new thoughts about this system stuff mmd, or do you still just think it's a 'load of crap'?

 

[militarymd]

Coming up on four years since we had this little discussion. Any new thoughts about this system stuff mmd, or do you still just think it's a 'load of crap'?

been through my share of M&M's and other mishaps......load of crap


each and every time, someone screwed up...and would like to blame someone for their mistakes/screw up.