Map of life expectancy at birth from Global Education Project.

Monday, April 07, 2008

It's nobody's fault

You've probably heard about the study that finds that over 7% of hospitalized children experience an adverse event from drugs, and given that some experience more than one, the total is 11 events per 100 hospitalizations.

That sounds appalling, but fortunately most of these events don't have any lasting consequences. Of course, they should never happen -- people are hospitalized to try to make them well, but hospitals are in fact dangerous places. It's not just the astonishingly high likelihood of being given the wrong medication, or too much of something. Hospitals are full of really nasty, antibiotic resistant germs, and the people in the hospital beds have extra holes in them with tubes going into the holes which help the bugs get in and out, among other unpleasant conditions. But we already know this.

What's new about this study is the rate of underreporting that it finds. Most of these errors were discovered only by critical analysis of the children's medical records -- noting that an antidote was given, or symptoms occurred which are probably medication side effects, etc. The responsible staff typically tried to sweep it under the rug. So, the new fashion is to try to modify hospital cultures and systems so that the incentives are to report errors, enable the administrators to make a full accounting of them, figure out why they are happening, and redesign procedures and the environment to make them less likely. That's how safety is handled in the airline industry, which does treat its customers like cattle in the chute at the slaughterhouse but, in the end, manages not to kill them very often. In fact flying is the ninth circle of hell, but it's quite safe. You might even be better off having your heart attack on an airplane than in the hospital, at least on a weekend evening. They have defibrillators and trained staff, and they'll get to you immediately. In the hospital, you might have to wait quite a long time.

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