On clinical hypocrisy

EMS systems, especially ones with big PR machines, like to claim how their clinical guidelines or protocols and their style of medicine are process driven.  Heck, one of the current trends in medicine that I really like are checklists because they remind us how to do the process right each and every time, thus accounting for human error.  These checklists and processes mean that, in theory, consistent patient care is delivered.  Consistency is important.  Heck, consistency explains why you stop at a fast food chain when traveling — you know what you’re going to get.

So, in theory, I like process-driven. Process-driven means you’re thinking about the big picture.  It means you’re accounting for the fact that your providers are human.  As such, humans make mistakes and need reminders, especially when you’re in the last hour of an overnight shift and you’ve been running without food, drink, or sleep for a while.

Here’s the rub.  When someone reports a clinical error in a process-driven system, should the outcome or harm to the patient matter?  Does a medication error become less serious when the patient doesn’t die?  Or, on the other hand, if you violate the process and the patient improves, does that mean there’s no clinical error?  It pains me to say that these claims of process-driven medicine are sometimes just that — claims.

When you lessen the consequences to your medics/employees because the patient wasn’t harmed, it’s not process-driven.  It’s not a “just culture” environment.  What it is is hypocrisy.  That’s right.  Hypocrisy.  Google defines it as: “the practice of claiming to have moral standards or beliefs to which one’s own behavior does not conform.”

What should EMS define these events as where the process is violated, but there’s no harm to the patient?  The simple answer from this attorney/medic is that you count your blessings, do a root cause analysis of how and where the failure occurred, and remediate, reeducate, or discipline as appropriate.

Here’s what The Joint Commission says:  “A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof.  Serious injury specifically includes loss of limb or function.  The phrase, “or the risk thereof” includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome.  Such events are called “sentinel” because they signal the need for immediate investigation and response.”

Until we consider clinical errors to be sentinel events that warrant investigation and response based not solely on bad outcome, but on “risk thereof,” we’re fooling ourselves into complacency.  Most importantly, we’re failing our patients.  “There but for the grace of God go I” should not be a reassuring whisper to oneself after an error occurs without harm to the patient.  Rather, it should be the words that strike fear into one’s conscience to make sure such a sentinel event is investigated, remediated, and addressed such that it may never happen again.

Comments

  1. Laurie Romano says

    The sentinel events are not necessarily the big danger. The big danger is the underlying hypocrisy.

  2. Man, I hear you clearly, but I think that the problem, as I’ve seen it, is that the motivations behind an investigation are very often not centered in resolution and improvement.

    The politics, both external and internal in many places, complicate or even nullify honest efforts, if honest efforts were ever intended.

    When I did my ambulance clinicals for paramedic we had two ambulances sitting side by side waiting for calls on a night shift. The crews (medic/basic) had met at this place because a paranoid schizophrenic came there every night for coffee. He would talk on the pay phone outside, to no one, as well as other things common to the condition.

    The crews had gotten the number for the pay phone and it seemed that it was their nightly ritual to call it as he walked by and say all kinds of terrible things to try and get him to ‘tip over’ and act crazy. It was easily the cruelest thing that I’ve seen in EMS to date, and one of my greatest shames that I was too much of a coward to stop it while it was happening.

    The next day, needing to mitigate my cowardliness, I went and saw the medical director for this service and reported it. He took careful notes, the service called me and proclaimed their gratitude for reporting it and asked me to come in a few days in the future and participate in the investigation.

    The day before I was to show I called and found that once they discovered who I was that they simply hung up the phone. I wasn’t contacted by them, but tried several times again to contact them, including the medical director, with the same result.

    I can’t pretend to know what actually happened, but my guess is that politics/CYA overruled process, as all of the people involved remained in place, but I was no longer allowed to ride with the service.

    We can’t change the hypocrisy, I believe, until we change the motivations behind it. And, man, I have no idea how to do that in an industry such as EMS.