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Obama administration proposes medical error reporting system


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Apparently someone in the government finally has noticed the FDA's Adverse Events Reporting System is not adequate for the scope of medical mistakes and unsafe practices. http://www.nytimes.com/2012/09/23/health/new-system-for-patients-to-report-medical-mistakes.html


New System for Patients to Report Medical Mistakes

By ROBERT PEAR NYTimes September 22, 2012


WASHINGTON — The Obama administration wants consumers to report medical mistakes and unsafe practices by doctors, hospitals, pharmacists and others who provide treatment.


Hospitals say they are receptive to the idea, despite concerns about malpractice liability and possible financial penalties for poor performance.


In a flier drafted for the project, the government asks: “Have you recently experienced a medical mistake? Do you have concerns about the safety of your health care?” And it urges patients to contact a new “consumer reporting system for patient safety.” The government says it will use information submitted by patients to make health care safer.


Federal officials say that medical mistakes often go unreported, and that patients have potentially useful information that could expose reasons for drug mix-ups, surgery on the wrong body part, radiation overdoses and myriad other problems that cause injuries, infections and tens of thousands of deaths each year.


Hospitals and even some doctors say the proposal has merit....


A draft questionnaire asks patients to “tell us the name and address of the doctor, nurse or other health care provider involved in the mistake.” And it asks patients for permission to share the reports with health care providers “so they can learn about what went wrong and improve safety.”


In seeking White House approval this month for a prototype of the reporting system, Dr. Carolyn M. Clancy, the director of the federal Agency for Healthcare Research and Quality, a part of the Public Health Service, said, “Currently there is no mechanism for consumers to report information about patient safety events.”


“Patient reports could complement and enhance reports from providers and thus produce a more complete and accurate understanding of the prevalence and characteristics” of medical errors, Dr. Clancy said.


Federal officials said the reports would be analyzed by researchers from the RAND Corporation and the ECRI Institute, a nonprofit organization that has been investigating medical errors for four decades.




Consumer groups welcomed the federal initiative. The American Medical Association had no immediate comment, saying it needed to study the details.


Some research suggests that one-fourth of patients in and out of hospitals experience “adverse events” in their care. Hospital patients interviewed by researchers in Massachusetts reported many events that were not documented in their medical records.


In the reporting system envisioned by the Obama administration, patients and their relatives would report medical errors and near misses through a Web site and in telephone interviews.


For each incident, the government wants to know “what happened; details of the event; when, where, whether there was harm; the type of harm; contributing factors; and whether the patient reported the event and to whom.”


The questionnaire asks why the mistake happened and lists possible reasons:


¶ “A doctor, nurse or other health care provider did not communicate well with the patient or the patient’s family.”


¶ “A health care provider didn’t respect the patient’s race, language or culture.”


¶ “A health care provider didn’t seem to care about the patient.”


¶ “A health care provider was too busy.”


¶ “A health care provider didn’t spend enough time with the patient.”


¶ “Health care providers failed to work together.”


¶ “Health care providers were not aware of care received someplace else.”


If the pilot project is cleared by the White House, health officials hope to start collecting information in May. Questionnaires would be made available at kiosks in hospitals and doctors’ offices. Fliers describing the project would be given out at pharmacies and mailed to patients’ homes with the explanation of benefits sent to them by insurance companies.


Reporting is voluntary, and federal officials said they would keep the information confidential.


A government script for follow-up interviews explains: “A medical mistake or error is an act or omission by a health care provider that most health care providers would consider incorrect at the time it happened. Some, but not all, medical mistakes can result in harm or injury to the patient.”


The government wants to know if the mistake involved the wrong medicine, the wrong dose of medicine or reactions to a drug; the wrong test or procedure, the wrong diagnosis or surgery on the wrong body part; or blood clots, infections, problems with anesthesia or “unclean or unsanitary care.”


Martin J. Hatlie, the chief executive of Project Patient Care, a health care safety coalition in Chicago, welcomed the federal plan.


“Patients and their families are a potential gold mine of information,” Mr. Hatlie said. “They see things that busy health care workers don’t see. Doctors are in and out. Nurses are in and out. But relatives are there continuously with the patient. They often know how to fix problems that cause errors.”


In recent years, Congress has taken steps to link Medicare and Medicaid payments to the quality of care, prohibiting payment for the treatment of certain medical errors.

This is not medical advice. Discuss any decisions about your medical care with a knowledgeable medical practitioner.

"It has become appallingly obvious that our technology has surpassed our humanity." -- Albert Einstein

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I appreciate this is a good move forward. However, I'd like to add to the list of reasons for the mistake:


1. health care provider in the pocket of big pharma.

2. health care provider's ego too big to listen to the patient experience.

3. health care provider willfully ignorant of adverse effects of taking and stopping medication.

4. health care provider willing to make it up on the spot.

5. health care provider heavily addicted to prescribing.

6. health care provider under the delusion that if it hasn't been researched, it doesn't exist

7. health care provider at too great a risk of litigation to diverge from the norm

8. health care provider has a high tolerance level for the adverse symptoms experienced by people other than themselves.



Sorry, I'm feeling a bit cranky today

Please note - I am not a medical practitioner and I do not give medical advice. I offer an opinion based on my own experiences, reading and discussion with others.On Effexor for 2 months at the start of 2005. Had extreme insomnia as an adverse reaction. Changed to mirtazapine. Have been trying to get off since mid 2008 with numerous failures including CTs and slow (but not slow enough tapers)Have slow tapered at 10 per cent or less for years. I have liquid mirtazapine made at a compounding chemist.

Was on 1.6 ml as at 19 March 2014.

Dropped to 1.5 ml 7 June 2014. Dropped to 1.4 in about September.

Dropped to 1.3 on 20 December 2014. Dropped to 1.2 in mid Jan 2015.

Dropped to 1 ml in late Feb 2015. I think my old medication had run out of puff so I tried 1ml when I got the new stuff and it seems to be going ok. Sleep has been good over the last week (as of 13/3/15).

Dropped to 1/2 ml 14/11/15 Fatigue still there as are memory and cognition problems. Sleep is patchy but liveable compared to what it has been in the past.


DRUG FREE - as at 1st May 2017


>My intro post is here - http://survivingantidepressants.org/index.php?/topic/2250-dalsaan

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  • Administrator

I'd use any of those reasons for a complaint!!!

This is not medical advice. Discuss any decisions about your medical care with a knowledgeable medical practitioner.

"It has become appallingly obvious that our technology has surpassed our humanity." -- Albert Einstein

All postings © copyrighted.

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