Models of Medical Risk / Misadventure

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GBHirsch@aol.com
Junior Member
Posts: 19
Joined: Fri Mar 29, 2002 3:39 am

Models of Medical Risk / Misadventure

Post by GBHirsch@aol.com »

The references shown below are for work done some time ago, but are relevant
to your query in that defensive medicine is an overreaction to medical risk
and an unintended consequence of dealing with it. Hopefully, the documents
are still available from MIT. Jim Potchen, one of the authors, is on the
faculty of Michigan State Universitys College of Medicine if contacting him
would help you get more information.

Gary Hirsch

Twine, Edgar H., & E. J. Potchen (1973). A Dynamic Systems Analysis of
Defensive Medicine. M. S., M. I. T. KW: health care Notes: For a reproduction
write to Microreproduction Laboratory, M.I.T., Room 14-0551, Cambridge
MA 02139.

Twine, Edgar H., & E. J. Potchen (1974). The Analysis of Defensive
Medicine: A System Dynamics Analysis. M. I. T. KW: health care Notes: For a
reproduction write to Microreproduction Laboratory, M.I.T., Room 14-0551,
Cambridge MA 02139.

From: GBHirsch@aol.com
Bill Braun
Senior Member
Posts: 73
Joined: Fri Mar 29, 2002 3:39 am

Models of Medical Risk / Misadventure

Post by Bill Braun »

While not directly SD related, the November, 1998 (Volume 76) issue of the
Milbank Quarterly had a number of articles on quality. The articles are
written by some of the authors of the Institute of Medicine report,
although I believe this volume predates the IOMs report.

Bill Braun
From: Bill Braun <medprac@hlthsys.com>
Ed Gallaher
Junior Member
Posts: 3
Joined: Fri Mar 29, 2002 3:39 am

Models of Medical Risk / Misadventure

Post by Ed Gallaher »

Dr. Lucian Leape, Harvard Medical School and School of Public Health,
has written a series of articles on these issues over the past 6-8
years. Many can be found in JAMA. They do not include SD models or
simulations, but are clearly based on a systems perspective.

I am a basic scientitst, not a clinician, but I work within a medical
school environment. Here are some of my own observations as a
"systems observer".

Starting with the fundamental concept: "System structure determines behavior."

AIRLINE
The airline industry clearly examines (i) individual performance, AND
(ii) system performance when investigating either accidents or near
misses. (Note the fact that they are even -investigating- "near
misses"; when is the last time youve heard of a "near miss" being
investigated in medicine?!)

- They examine the communication between pilots and controllers;
possible confusion within the cockpit; equipment failures; fatigue .
. .
- Pilots are trained in flight simulators.
- Each flight begins with an inspection of the plane, from a
well-thought-out and pre-approved check list.
- Military flight missions include careful prior briefings of every
detail, and debriefings afterward.

MEDICAL
- Interns and residents typically work 24-36 hour shifts.
- Patients see multiple doctors and obtain meds from multiple
pharmacists. Rarely are all these providers in contact with each
other.
- A "state-of-the-art" Rx review is the "brown bag session" with the
physician. I AM NOT MAKING THIS UP!
- It is not uncommon to find a patient taking the same drug from two
sources, with different brand names.
- It is estimated (fairly accurately) that about 20% of all nursing
home admissions are due to inappropriate long-term overdoses and drug
interactions. (Think of this; Mom is getting forgetful and a little
unsteady-- sell the car, the house, the furniture -- move from
familiar surroundings -- enter the nursing home -- review medications
(all 9 of them, perhaps 6 months later); eliminate many of them and
reduce doses of others -- Voila! Moms not so forgetful or unsteady
anymore!)
- Industrial gas tanks and valves are different sizes; male and
female; right- and left-hand thread to avoid catastophes such as
connect H2 to an O2 regulator. In contrast, all syringes are the
same. It is not uncommon to pick up the wrong syringe and mix up two
drugs.
- Mistakes are most commonly dealt with by disciplining the
individual, or providing more training. (Hmmm, could the -structure-
of the system be a contributing factor?)
- Dr. Leape was previously a pediatric surgeon. Largely knowing the
answer, I asked him about checklists in the operating room. Given the
culture of the medical community, this would NOT go over very well.
Even for the most complex procedures (in fact, -particularly- with
the most complex procedures) we dont want to suggest the surgeon
might need a check list. (Leape was not condoning this attitude; just
describing reality.)
- To be consistent, should we not absolve our highly experienced 747
Captain from checklists? Checklists just create an atmosphere of
incompetence and lack of confidence, dont they? ( . . . .
well, dont they?)

There may be some opportunities for System Dynamics in this arena.

EJG
From: Ed Gallaher <gallaher@ohsu.edu>
--
Edward J. Gallaher, Ph.D.
Research Pharmacologist
Research Service R&D17
Veterans Admininstration Medical Center
Portland, OR 97201
(503) 220-8262 x56677

Associate Professor
Depts. of Behavioral Neuroscience
and Physiology-Pharmacology
Oregon Health Sciences University
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