Paths lead from one place to another. In computers they are expressed by a succession of landmarks separated by slashes.
is a path that would get a Californian to the east coast. Routing determines destinations. We must start with Truth. Otherwise we do not know where we are. If we do not move from there we will not get where we need to go.
Patient Safety cannot be reached on the current path, which probably best can be expressed as /TrustUs/. We have been doing that for 200 years and it might be our most fundamental problem.
It is not exclusively about trust.
However, at the very least, our systems must be able to address issues of trust. When our feedback structures are such that they do not address even unfriendly practices, of what use can they be with regard to subtler issues? At the bare minimum in those cases we must be able to arrive at truth and proceed to justice.
The Institute of Medicine defines patient safety as freedom from accidental injury. Apparently when patients are injured on purpose they still are safe. The Agency for Healthcare Research & Quality, in its Five Steps to Safer Health Care, mentions only steps that might help if the caregivers involved are competent, interested, honest and unconcerned about how the careers of their colleagues and their own careers and reputations might be effected.
These are agencies whose vocabularies and concepts are derived entirely from the self-interested view of caregivers. These are agencies more worried about ruffling the feathers of caregivers than protecting the patients who have been raped by them.
You cannot claim to be on the side of patients if you do not acknowlege the most fundamental problems for patients.
Is there anyone in medicine who even understands why it is important?
The Opposite of It
To understand a system you must look at its worst case scenarios. That is where you see how the system operates. In our current system when a patient becomes the victim of an adverse event, the health care system turns on that patient (and manages to persuade itself that the problem is the patient). It is not merely untrustworthy. It is aggressively atagonistic. It circles the wagons to protect itself at the expense of the patient. To see that in its most glaring light, examine instances in which the adverse event is not an accident.
Look at what happens when a patient complains of exploitation or abuse. If you want to see how physicians manage to avoid creating records or diagnosing injuries, watch what happens when a patient seeks treatment after being injured intentionally. That is where you get a true picture of the mechanisms by which smaller, more subtle problems do not get prevented or reported in medicine. That is where you see the most fundamental problems for patient safety.
Hens Trusting Foxes
Without addressing issues of trust, we never are going to make significant progress on the more modest goal of solving accidental injuries. A means for patients to respond to injuries must be put in place, partly because physicians and nurses do not advertise adverse events. They cover them up. Especially when the cause was intentional. And inspite of how dire the consequences are for the injured patients.
Increasing Future Injuries
Injured patients frequently cannot get diagnosed, let alone treated, because of how unified medical practitioners are in protecting each other. No one wants to create a record that indicts other healthcare professionals. The only recourse patients have had in the past was to travel far enough to find healthcare professionals who did not have access to the network that would damage the career of the practitioner who helped the injured patient. The ability to escape a prejudiced network may be lost with the new electronic health information systems. It could enable iatrogenic injuries to be covered up nationwide more easily than they currently can.
Part of what might be necessary is for patients to be given control over their records, like the ability to expunge or seal portions, or possibly all of them. How else to escape the influence of a caregiver who believes his/her career depends on making sure the rest of the medical establishment regards the injured patient as a crank with a frivolous grievance?
The definition of patient safety and the list of steps to safer healthcare need to include explicit mechansims for protecting patients from untrustworthy caregivers. The medical community turns up its nose and does an about-face whenever this is mentioned, but if patient safety initiatives do not address crime they are shallow. The least patients should expect is to be safe from violence and sex abuse and the other abuses in which humans indulge when getting away with them appears likely. Right now you would be hard pressed to find a safer place to abuse people than in medicine.
From the outside it looks as though these crimes would be hard to cover up because there are multiple sources for information about those crimes. But none of them are honest. It appears that one person could not write a patient's history in a self-protecting way. But patients who have been on the wrong end have routinely discover how all the parties involved manage to create records that provide no indication of what occurred.
That Is Routine
There is little worth salvaging from current feedback structures. A new architecture has to be erected. It will have to exist outside of the institutions currently charged with ensuring truth, justice and patient safety as their conflict of interest prevents them from ever becoming good caretakers of patient safety. With unrecognized, self-serving, self-deception (see Agnotology) they brush off statistics and examples as being unimportant or unbelievable or too rare with which to be bothered.
What are the obstacles?
The people who know the obstacles best, injured patients, are sued if they speak (see freedom of speech for patients). The culture of silence (see silence versus safety and risk management) prevents the worst problems from being reported by healthcare professionals. And, at present, there is no other source for the most necessary information to form a clear picture.
But There Could Be
There is little appreciation of the extent to which the data is corrupt. Health care professionals march on basing their decisions on records that reveal accurately only 2% of what goes wrong in medicine (according to the Health and Human Services and others - see Medical Reporting) and then scratch their heads wondering why the rates of unnecessary death do not decline. Actually, what happens more often is caregivers imagining they see great improvements in their own practices after efforts that address, perhaps, 3% of what is wrong. They don't see the rest and are happy that most of what they do see was improved. For instance, try to find a caregiver with any awareness of unfriendly practices.
The patient safety movement is working hard on efforts that cannot solve the real problems. But they feel good about their hard work while dismissing the issue that is the bellwether for all of patient safety - crime in medicine. As long as we do not have structures capable of discovering and responding to that, we don't have structures sufficient for dealing with anything in a meaningful way.
Crimes rarely are reported. The patients who are injured rarely are recognzied, let alone helped. Patients continue to die unnecessarily in unacceptably large numbers year after year and will continue to until this changes. Medicine continues to be a virtually lawless place where witnesses do not report even rape and homicide (see Orville Lynn Majors), victims are sued into silence and offenders operate with impunity. The extent to which this is true is something to which the medical community is oblivious. And, unfortunately, the patient community believes the information it gets from the medical community.
Developing the Vocabulary
The stories that make patient safety issues understandable are not allowed to be told. I have been forced to remove them from this site. And numbers, like the amount of assault, rape and homicide in medicine, are brushed off as though they are not important.
Patient safety is a path. We must start with knowing what's true. That is what mandatory reporting measures have been enacted to address, but, as was predicted on this site, they make no difference. That, perhaps, is the first issue of trust that should be addressed.
The information gathering system must expand so that self-interested health care professionals who are loyal to each other are not the only source of information. Currently, sufferers of iatrogenic injuries cannot even get their stories into their medical records, whether the injuries were inflicted accidentally or not. And those injured patients are not merely left behind. They are crushed and defeated by dishonest operators in a system that has no checks or balances in the realm of these issues.
I defy you to find someone in medicine who understands this. They have a culture of rationalizations that allow them to define what they are doing in self-serving ways, and to prevent information to the contrary from reaching them.
Ye Shall Know the Truth
Unless Ye Work in Medicine
First we must be able to establish what is true. Then we must establish a mechanism that responds to it, especially when the truth is sinister. Only then will be able to proceed to safety.
The very least a patient should be able to expect in medicine is to be protected from intentional injury and/or exploitation. Currently the only systems in place are ones that protect the perpetrators at the expense of the patients. And all we hear from people in medicine is that they are the ones who need to be protected, as though the suits and grievances brought against them are frivolous. They aren't (see Studdert). Caregivers have set up their information collection systems to support their self-serving view of the world. They are not the ones who are dying. And they do not want to be aware of the ones who are.
It is not just the system that is sick.