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Tuesday, October 17, 2006

It’s the System, Stupid!

We like to think that we can count on our physicians to make sure that we receive good medical care.

There seems to be more to it than that.

The October 2, 2006 issue of the Annals of Internal Medicine reported a retrospective review of 307 closed malpractice claims by a team of Harvard and University of Texas researchers.

59% of those claims were found to involved diagnostic errors that harmed patients. Of those, 30% resulted in death.

In 55% of those cases, there was a failure to order an appropriate diagnostic test. 45% of the time, a proper follow-up plan was not followed. 45% of the harmed patients did not get a proper history taken or physical exam performed. Diagnostic tests were incorrectly interpreted for 37% of them.

Factors contributing to the errors included failures in judgment (79%), vigilance or memory (59%), knowledge (48%), patient related factors (46%), and handoffs (20%).

The study concluded that diagnostic errors that harm patients are typically the result of multiple breakdowns and individual and system factors. In other words, the chance of a good outcome in modern healthcare depends not only on the doctor, but also on the system of which the doctor is a part.

We don’t want to believe that, but the numbers speak for themselves.

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