Time to take a hard swing at the ‘wall of silence’ surrounding medical error

The timing may or may not have been coincidental. Either way, the upshot is encouraging.

In early May a Johns Hopkins study showed medical error to be the third leading cause of death in the country. Only cancer and heart disease are fatal more frequently.

Three weeks later, the federal government’s Agency for Healthcare Research and Quality rolled out a package of written materials, slides and videos—AHRQ’s “Candor” toolkit—aimed at helping hospitals do the right thing when a patient is harmed.

The toolkit is free, customizable and, to my eye, commendably easy to use.

It’s also grounded in lessons learned from the agency’s $23 million Patient Safety and Medical Liability grant initiative launched in 2009, which suggests the Hopkins study only hastened rather than outright spurred its release.

In any case, the most impressive part of the AHRQ action may have been the words of the agency’s new director, internist Andy Bindman, MD, in introducing the toolkit.

“Medical harm,” he said, “can impact patients twice—first by the harm itself and then by the wall of silence that can follow.”

That struck me as not just candid but courageous.

One could even argue it was the 2016 healthcare equivalent of a Nixon advisor having the guts to tell the boss, circa 1973: 

The break-in by our guys at the Watergate was bad enough. Covering it up is only going to make things worse for the American people. Do right by them and tell the truth.

If only.

Of course, the Candor toolkit is only going to be as effective as the provider orgs using it.

Or as ineffective as those ignoring it.

And make no mistake: The key issue here is communication, and radiology is anything but exempt.  

The accomplished and influential radiologist Leonard Berlin, MD, pretty well nails it in a piece running in the current issue of Radiology Business Journal.

“Sending a computerized radiology report to a referring physician is metaphorically similar to a baseball batter getting on base by a hit or a walk,” he writes. “Such action is indeed rewarding, but it is meaningless if the runner is stranded on base and does not score a run by crossing home plate.” 

In baseball, Berlin points out, the worst that can come of the stranding is a larger number in the loss column.

“In medicine,” he adds, “the worst that can happen is that a patient is severely harmed and/or dies.”

May many a provider step into the batter’s box and play ball with AHRQ’s new toolkit.