In the other book, surgeon Atul Gawande described how he almost lost an Emergency Room patient who had crashed her car when he fumbled a tracheotomy only for patient to be saved by another surgeon who successfully got the breathing tube inserted. Gawande also has a chapter on doctors’ errors. His point, documented by a paper in the New England Journal of Medicine (1991) and subsequent reports is that nearly all physicians err.
If nearly all doctors make mistakes, do they talk about them? Privately with people they trust, yes. In public, that is, with other doctors in academic hospitals, the answer is also yes. There is an institutional mechanism where hospital doctors meet weekly called Morbidity and Mortality Conferences (M & M for short) where, in Gawande’s words, doctors “gather behind closed doors to review the mistakes, untoward events, and deaths that occurred on their watch, determine responsibility, and figure out what to do differently (p. 58).” He describes an M & M (pp.58-64) at his hospital and concludes: “The M & M sees avoiding error as largely a matter of will–staying sufficiently informed and alert to anticipate the myriad ways that things can go wrong and then trying to head off each potential problem before it happens” (p. 62). Protected by law, physicians air their mistakes without fear of malpractice suits.
Tameika Fraser on 28 Feb 13An iPhone app that allows teachers to call more parents, more often. With Dash, teachers can log student performance and generate a daily speed dial of parent numbers. At the end of each conversation, Dash instantly creates a call log and analytics that inform future parent contact and ensure no student is overlooked. Parent engagement and data that teachers need to fast-track student success are now only a click away.
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