Medicine steadfastly misdirects the conversation about patient safety in ways that protect its own interests and its image of itself by referring to the problems harming patients with words that limit the parameters of what is discussed.
The words "error" and "mistake" are not catchall words that describe all of the problems harming patients. They are misdirections that paint a picture of innocent, well-meaning people once in a while having things happen on their watches that are no one's fault.
For instance, 93% of the time when negative events occur in medicine they are not reported anywhere at any level according to the United States Department of Health and Human Services (see Medical Reporting). There are many reasons for this including, frequently, cover-ups.
Cover-ups occur nearly every time patients are injured (talk to a few hundred injured patients, like I did, if you doubt that, and perhaps glance at blacklisting). Cover-ups are not mistakes or errors. They are sins that create an additional layer of harm for patients who are seeking help for the injuries acquired from treatment but who have no accurate record of what the injuries are or how they got them. As a result they have a reduced ability to get care for the injuries, especially given the reluctance of anyone in medicine to believe a patient has iatrogenic injuries, let alone create a diagnosis of them that could give a patient a means to complain about it. So patients already injured by treatment are additionally injured not by medicine making a mistake or error, but by medicine protecting itself at the expense of patients.
Also, what about incompetent practitioners who are allowed to keep practicing for political reasons? What about all of the nurses and doctors who cannot be persuaded to wash their hands enough? The resulting injuries cannot be called errors.
What about policies that save money even though a certain number of patients will die and a larger number be injured as a result? What about unnecessary treatment to make money?
Nearly all of these events are covered up with inaccurrate records. The resulting injuries are dismissed as innocent errors.
The word "Error" misdirects us
To use the wrong term is to misunderstand the problems and do the wrong things to protect patients. I suspect that one of the reasons that we stubbornly persist in pursuing the exact same solutions that have not worked in 160 years (see Myth #1), without learning that they never have and never will work, could be how we are hamstrung by how our thinking is limited by using terms that mislead us.
"If you don't measure the right thing, you don't do the right thing." - Josephe E. Stiglitz, Nobel Prize winning economist.
If you don't describe the right thing you don't measure the right thing.
Description is Prescription
Statistically, in hospitals 20 to 25 unsafe acts are committed per patient per day. They result from bad habits, bad management, bad training, being in a hurry, being unaware of the resulting injuries and so either not being attentive enough to prevent them or simply not being aware that the acts are unsafe. All these are different than being properly trained, aware, attentive and not in a hurry and finding oneself saying "Whoops" as one may after accidentally making a mistake.
A much longer list could be written about the problems harming patients that are not mistakes or errors. Every one of them is excluded from the discussion when the subject only is mistakes and errors. These events at least should be acknowledged harm rather than being mischaracterized as innocent slip-ups a certain number of which necessarily will occur in any large enterprise.
Phrases like "Patient Harm" or "Safety Issues" or "Dangerous Medicine" are better than "Errors" or "Negligence." Among other things, the words Error, and even to a certain extent the word Negligence, forgive and enable the worst causes of harm. We only pretend to attend to safety issues when we exclude from the discussion all the rest of the problems harming patients. The worst problem are not errors or mistakes.
A Scholastic Term
Nequamitis is a word should be in the title of a speech once in a while. Sometimes it should be the label on a file folder or part of the name of a blog or a committee or of a course in college.
Nequamitis is a word that prevents excluding from thought and discussion problems that are worse than errors, more numerous than negligence, and more sinister than either. Sometimes accuracy is the difference between life and death.
Nequamitis refers to the whole panoply of problems harming patients in medicine, from graft to abuse to incompetence to errors to murder to negligence to falsified records. It is important not to eliminate from the discussion the worst problems. Otherwise we are doing the equivalent of protecting people from gnats, and only gnats, when the people are walking through mine fields.
(neck' wahm itis)
"Nequam" is Latin for worthless, good for nothing, or bad. "Itis" is a suffix derived from Greek meaning inflammation. When a caregiver or a treatment causes injury to a patient, at the very least that caregiver or treatment was not good for that patient. When the whole field of medicine injures and kills as many patients as it does in as many ways as it does, it is unacceptable to dismiss from thought all the forms of harm other than the innocent mistakes and errors.
We know how to prevent 200,000 patients per year from dying from blood clots in hospitals. Only one hospital that we know of has tackled the problem and solved it. The solution is known and has been published. When every other hospital in the country has better things to do than save those lives, they are not making errors. They are making choices. The resulting fatalities are not errors. The terms we use should not address them as though they were.
Our terminology must not exclude the many small acts of volition committed by providers for their own benefit, but that result in a cumulative damage to patients that is enormous. Our terms must not exclude the willful cover up that follows nearly every event that harms, or even could have harmed, a patient, whether by accident or not. Our terms must not exclude awareness of the health care professionals who do so much harm that they should have been removed from the profession long ago but instead are protected and allowed to practice. Words like Error and Negligence mischaracterize and exclude all of that and things worse than that. Terms like Medical Harm and Patient Harm are better, but the term Nequamitis should in the background ready for use in particularly important situations, like when your communication is intended for a committee of health care professionals discussing the issue.
When the subject is Errors the adjoining words tend to be words like Reducing or Avoiding. When the subject is Nequamitis they can be words like Healing or Curing since it is an affliction.
Errors easily are dismissed by the people causing the harm. They rationalize that everyone makes errors. You cannot expect any system to be completely error-free. And tweaking systems isn't normally part of the job description of a health care professional.
But curing afflictions is
Nequamitis is a term that is not just more inclusive of the problems about which something needs to be done. It is a word that allows better ways of thinking about them, especially for members of the health care profession. Curing is in their job description.
If we are not going to use a word like that, we at least should use inclusive phrases like "patient harm problems" or "safety issues" or "dangerous medicine" or "sins and errors." We've got to start talking about what actually is wrong rather than what it is comfortable for health care professionals to hear.
Sins and Errors
At least "sins and errors" acknowledges that there is more harming patients than innocent slipups that are no one's fault.
Even when it is innocent
Errors are not the problem. They are a symptom of the problems. How likely is a cure to be found when the focus is on the symptom rather than the cause?
Let us diagnose, treat and cure Nequamitis so that patients may be well.
This page is an abbreviation of:
"The word Error in Medicine"
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Fifteen years ago when I first started making this point, everyone argued with me. Most patient safety advocates would declare, often angrily, that we had to keep cordial relations with health care professionals so that they would work with us. Others would assert that not all injuries are intentional (maybe in another fifteen years some will see why intentional injury is where we must start). But this year, 2013, a patient safety advocate with whom I had been communicating for at least five years became the first person to read something I'd written about what is wrong with pretending it's all errors and virtually slap his forehead over how obvious this is and yet he'd never thought about it. A few months later began a trickle of people learning about this page and sending me notes of agreement.
We have been in neutral - loud but making no difference in the numbers of bankruptcies, injuries and deaths - possibly because we were not talking about the real problems. Maybe we are about to start.