dr.nikhil datar
TRANSCRIPT
1991, Harvard medical practice study
1999, IOM :” To err is human”
Studies from Australia and other countries
Patient safety
Dr Lucian Leap
“Many people in the healthcare profession and
in the general public still believe that mistakes in
medical care are episodes of individual failure
and that most errors occur as a result of
someone not doing his or her job.” ---Don Burwick (Achieving safe and reliable health care)
Inferences:
•Out of the 3.7% cases, the acts which could be
called as “negligence” were only 1%.
•50% of these are preventable.
•The majority of them were not individual failures
but the system failures. It was a defective system
which was just waiting to fail.
With Sir James Reason
57 per 100000 deaths happen due to unintended injuries..It is the 9th cause of mortality in the world.
Medicine is complex
• Harvard Venuguard query:– 250 primary problems+ 900 secondary
problems+300 medicines+ 100 diagnostic tests+40 procedures
– In ICU settings , 179 procedures per day .. Which can prove dangerous.
Philosophy of errors
• Ignorance• Ineptitude
– Samuel Gorovitz ( journal of medicine and philosophy, 1970)
• Situational Awareness
How reliable is health care?
1000010010 1000 1million 10million100000
hazardous Ultra-safe
Bungee jumping
Mountainclimbing
Chemical manufacturing
Scheduled airlines
European rail
Nuclear power
health