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Did the hospital use a medical checklist? This is a question that I like to ask everytime a medical procedure went wrong, because a checklist is a very useful t

by kiba 14y ago

Did the hospital use a medical checklist? This is a question that I like to ask everytime a medical procedure went wrong, because a checklist is a very useful tool in saving lives and preventing medical errors. However, the medical checklist haven't been adopted as fast as it should.

neurotech1 14y ago
As tragic a loss as this is, I'm not sure that this was a simple 'skipped check' complication. Chemotherapy does sometimes result in complications like organ failure even if no actual errors are made. I'm not a physician, but I'm did fly as a pilot and learnt all about checklists. Capt. Sullenburger would like to apply the lessons in his 40 years of flying, to the healthcare industry.
mamp 14y ago
I don't think it is helpful in this situation to insinuate that medical error was involved, or that Mr Hunter's death was preventable. Also, thinking that a simple checklist will solve medical error reflects a very simplified view of the problems in the health care system. There are a lot of smart people in health, if the solution was simple the problem would have been solved by now. Not knowing anything beyond the post about Mr Hunter's situation, in general advanced colon cancer may involve surgery (to prevent blockage) and chemo. These are risky and have high chances of complications. In this sad situation there are no good options, only less bad ones. From the post it appears he fought bravely and was dignified. Very sad.
- knowtheory 14y ago
  While i agree that there's nothing to indicate there was neglect or that this death was preventable, please please do not assume that checklists would not help. Doctors and nurses are humans (usually exhausted over worked humans). Checklists save lives and make sure that folks are all on the same (literal) page in aviation, spaceflight, engineering fields of all stripes and other fields where life and limb are at risk. Just because you're smart doesn't mean you can't make mistakes. Engineer your environment to minimize mistakes.
- beagle3 14y ago
  > I don't think it is helpful in this situation to insinuate that medical error was involved, or that Mr Hunter's death was preventable. I agree. > Also, thinking that a simple checklist will solve medical error reflects a very simplified view of the problems in the health care system. Indeed, yet, a simple checklist HAS been shown to significantly improve outcomes: http://www.npr.org/templates/story/story.php?storyId=122226184 http://www.npr.org/templates/story/story.php?storyId=1222261... . > There are a lot of smart people in health, if the solution was simple the problem would have been solved by now. This is completely and utterly wrong: All stable systems past their transient stage are generally at a local optimum for their respectively relevant utility function - which is shaped by the incentive structure. Unfortunately, the incentive structure in medicine is all about avoiding liability, then making money, and actual care is a side effect. As a result, small changes can produce dramatic change in care quality. But (almost by definition) they increase liability in the short term regardless of merits (because "that's not standard practice"), and are rarely practiced.
  - mamp 14y ago
    I've spent the last 20 years in the area of patient safety and reducing medical error -- the last 10 years in building technology to assist clinical staff in improving safety. You are correct in saying the incentives are not right, but regardless, many people are in health to help people. Reducing error is hard because the 'system' isn't designed for safety (it basically isn't designed). Checklists are used often, but aren't the solution. There are about 100 things that have to line up to get health right, saying 'checklists _alone_ will solve it' trivialising the problem. The challenge is how to improve patient safety while improving clinical workflows. Everyone is under a lot of pressure and adding more stuff for them to do just fails.
deleted 14y ago
[deleted]
Udo 14y ago
Medical professionals are often dragging their heels on progress as a matter of course, but in this case I believe the allegation is unfounded. Chemotherapy is a very dangerous treatment. It's essentially an injection of pure poison, and often people do die from complications of cancer treatment as opposed to dying from the cancer itself. Cancer drugs are terrible. Cancer surgery is often devastating. The worst thing (though maybe somewhat of a consolation in this case) is there is no real cure. If he was diagnosed with advanced colon cancer and pushed straight into chemo, chances are the treatment was just a palliative measure designed to give him a few more weeks with less discomfort.

by kiba 14y ago

neurotech1 14y ago

As tragic a loss as this is, I'm not sure that this was a simple 'skipped check' complication. Chemotherapy does sometimes result in complications like organ failure even if no actual errors are made. I'm not a physician, but I'm did fly as a pilot and learnt all about checklists. Capt. Sullenburger would like to apply the lessons in his 40 years of flying, to the healthcare industry.

mamp 14y ago

I don't think it is helpful in this situation to insinuate that medical error was involved, or that Mr Hunter's death was preventable. Also, thinking that a simple checklist will solve medical error reflects a very simplified view of the problems in the health care system. There are a lot of smart people in health, if the solution was simple the problem would have been solved by now. Not knowing anything beyond the post about Mr Hunter's situation, in general advanced colon cancer may involve surgery (to prevent blockage) and chemo. These are risky and have high chances of complications. In this sad situation there are no good options, only less bad ones. From the post it appears he fought bravely and was dignified. Very sad.

knowtheory 14y ago
While i agree that there's nothing to indicate there was neglect or that this death was preventable, please please do not assume that checklists would not help. Doctors and nurses are humans (usually exhausted over worked humans). Checklists save lives and make sure that folks are all on the same (literal) page in aviation, spaceflight, engineering fields of all stripes and other fields where life and limb are at risk. Just because you're smart doesn't mean you can't make mistakes. Engineer your environment to minimize mistakes.
beagle3 14y ago
> I don't think it is helpful in this situation to insinuate that medical error was involved, or that Mr Hunter's death was preventable. I agree. > Also, thinking that a simple checklist will solve medical error reflects a very simplified view of the problems in the health care system. Indeed, yet, a simple checklist HAS been shown to significantly improve outcomes: http://www.npr.org/templates/story/story.php?storyId=122226184 http://www.npr.org/templates/story/story.php?storyId=1222261... . > There are a lot of smart people in health, if the solution was simple the problem would have been solved by now. This is completely and utterly wrong: All stable systems past their transient stage are generally at a local optimum for their respectively relevant utility function - which is shaped by the incentive structure. Unfortunately, the incentive structure in medicine is all about avoiding liability, then making money, and actual care is a side effect. As a result, small changes can produce dramatic change in care quality. But (almost by definition) they increase liability in the short term regardless of merits (because "that's not standard practice"), and are rarely practiced.
- mamp 14y ago
  I've spent the last 20 years in the area of patient safety and reducing medical error -- the last 10 years in building technology to assist clinical staff in improving safety. You are correct in saying the incentives are not right, but regardless, many people are in health to help people. Reducing error is hard because the 'system' isn't designed for safety (it basically isn't designed). Checklists are used often, but aren't the solution. There are about 100 things that have to line up to get health right, saying 'checklists _alone_ will solve it' trivialising the problem. The challenge is how to improve patient safety while improving clinical workflows. Everyone is under a lot of pressure and adding more stuff for them to do just fails.

deleted 14y ago

[deleted]

Udo 14y ago

Medical professionals are often dragging their heels on progress as a matter of course, but in this case I believe the allegation is unfounded. Chemotherapy is a very dangerous treatment. It's essentially an injection of pure poison, and often people do die from complications of cancer treatment as opposed to dying from the cancer itself. Cancer drugs are terrible. Cancer surgery is often devastating. The worst thing (though maybe somewhat of a consolation in this case) is there is no real cure. If he was diagnosed with advanced colon cancer and pushed straight into chemo, chances are the treatment was just a palliative measure designed to give him a few more weeks with less discomfort.