I was planning on responding to one of the comments from yesterday's post. I was planning to say that, yes, we do have a system for reporting errors and other incidents, but it doesn't seem like anyone uses it, I have no idea where the information goes, and certainly no one ever talks about using it, or has ever encouraged us to use it. So, it's a great system.
For dramatic purposes, let's imagine I was writing that post, when one of my medical students interrupts me.
"Doctor, we're back from that test you had us accompany the patient to."
"Oh, great. I wanted you to get a chance to see an actual procedure done on one of our patients. Was it interesting to watch?"
"Uhhhh... sort of. It was awkward."
"Yeah, the doctor was kind of yelling at the nurses."
"And the patient."
"Yeah. She wasn't fully sedated, and she was struggling a little when he put the tube in, and he started calling her names--"
"Maybe he just wanted to make sure she didn't get hurt--?"
"He slammed her head down on the bed pretty hard."
"He did what??"
"Yeah, we were all looking at each other and felt really uncomfortable, because it definitely seemed like he crossed a line. Should he have been that rough with a patient?"
"Rough is really not a word you should ever be using to describe how a doctor is treating a patient."
"And we didn't want to say anything, because he's an attending and we're just students--"
"Of course. That's obviously a very awkward position to be in. And the other students felt the same way?"
"Yeah, we were talking about it the whole walk back here. We're not sure if there's something we should do, some way to report this. Oh, he also called her crazy, and then said she won't remember anything anyway because of the sedation."
"This seems like a setup for something they would use to test whether people use the incident reporting system."
"So you think we should report it?"
"How do we do that?"
"I don't know. But let me figure it out, and then later I can show you and we can definitely report this. I don't want you to think that's an appropriate way for doctors-- for anyone-- to behave. To anyone, let alone a patient. And you're sure this couldn't have been interpreted in some other way?"
"Uh, yeah. We were all pretty scandalized."
......So I find the incident reporting website, and it's broken. I call one of the administrators, who's never heard of the site. He refers me to another administrator, who tells me I have to sign up for a username and go to another site. He refers me to another administrator......
"Are you sure you want to report this?"
"Are you sure you want to ask me that? Why wouldn't I report this? I think it's a valuable lesson for my students, and definitely not an appropriate way to treat patients."
"But you want something to be in writing? Maybe you should talk to the attending first."
"I didn't see what happened. My students did. I don't think they should have to talk to the attending. There's a good reason something like this can be reported anonymously. It shouldn't be the responsibility of the students to have a conversation with an attending about how he treats patients. It needs to be reported, and investigated."
"Come on, it starts a whole process."
"Uh, yeah, that's the point."
"And you're sure you have all of your facts straight?"
"I have the facts of what my students-- three of them-- all agree they saw, and I think it rises to a level where there should be further investigation. I'd rather err on the side of patient safety."
"I'd rather you err on the side of not reporting things. I wouldn't want you to regret it down the road."
"Can you please just tell me how to log in to the system?"
.....So, yes, we have a wonderful incident reporting system, and it works tremendously well to protect our patients and our staff. My students filled out the form. The system shot them back an error message. They will be submitting it by hand tomorrow. And, I fear, and unfortunately expect, that no one will ever hear anything about it again. Excuse me while I go slam some patients' heads into the wall.