Patient Safety - Reality Check

Management Issues

When a succession of leaders maintains a specific mismanagement style, like the Renaissance Popes, it is a serious problem. The Renaissance Popes worked within the cognitive framework of that church in that age. They failed to respond to the world around them, brought themselves into disrepute and contributed to the deterioration of their authority.

It is interesting that the psychology of caregiving is so compelling on both sides of the equation that the way our health care is managed kills hundreds of thousands of us annually without bringing itself into disrepute in either its own eyes or the eyes of its patients.

What is the cognitive framework of medicine now?

The most rudimentary cognitive framework must include memory structures, action structures, and executive processes. Repeatedly on this site I address the memory structures. It is the goal of risk management to defeat them at every level. Without them, patients will continue to die unnecessarily.

Memory structures range from temporary working memory to the nearly permanent memory of archived records. In between is episodic memory, a history of efforts to address existing problems. It almost doesn't matter what action structures and executive processes exist if memory structures are deficient because memory deficiency eventually will cause those other components to be so out of touch that the system will destroy either itself or its constituency.

Basic to modern medicine are efforts to manage risks by dissuading employees from keeping journals and efforts to dissuade them from responding to events in a way that would create a memory of them (see risk management). These are conscious attempts to prevent the system from having a short term memory and to prevent conversion of it to long term memory.

The effort to protect the reputations of doctors by keeping information about them private reduces the systems ability to retrieve memory. It erases "truth," the first step in the path to patient safety.

Truth is more important than the reputations of doctors and nurses and hospitals. Justice is more important than collegial loyalty. Lives are more important than liabilities. One shudders even for having to say it. But in medicine they believe the opposite of each of those points. It would be difficult to be more hostile to the well-being of the patient community without intentionally killing them.

What are some of the assumptions of medicine now?

  1. That keeping track of problems is not necessary because problems are so rare (this is expressed to me continually by doctors and it's a product of their own blind faith, not data).
  2. That systems can be set up as though all caregivers are well-meaning.
  3. That liability is more important than safety.
  4. That no one but doctors can understand or police doctors.
  5. That criminal law does not apply in medicine.
  6. That the reputations of doctors are too important, and patients too stupid, to allow patients to discuss and know them.

Some might regard those assumptions as the definition of folly.

The assumptions are self-centered.
The cognitive framework is self-serving.
Both block the path to safety.

People with egos the size of Antarctica, and unlimited access to poisons and weapons (prescriptions and scalpels), are managed as though there could be none among them who would do a bad thing. This might be especially true in hospitals like Catholic hospitals.

Administrators trying to earn a profit care about different management issues than do the patients who are trying to avoid being disabled or killed, but in the final analysis, medicine is for patients, not profits and jobs. So the issues most important to patients should be at the top of the list. So far they are not.