404 Moment
404 moment: Inability to find the medical file of a patient, often leading to medication and treatment errors and unnecessary tests. From “404 error: File not found” seen on web browsers.
The sentinel event health report is dues out today, detailing all the errors made in the health services with poor (sentinel) outcomes. I would have no problems with this report if it was going to be used to improved the shoddy safety systems in place in hospitals, in which the 404 moment is distressingly common, to mention just one systemic error.
Unfortunately, what will probably happen with this report, is that it will be used gleefully by the media to create lots of bad news stories about health (the only kind the MSM actually like). Even worse, I suspect the report will be used by Tony Ryall as a cudgel against certain DHBs, achieving nothing accept some political point-scoring.
The vast majority of errors in medicine are caused by endemic system failures such as the 404 moment. They are rarely caused by incompetent medical personnel. A tired house surgeon should not be able to chart 100mg morphine without warning lights flashing, nor should a tired nurse be able to give it without the system insisting that it is triple checked. A good system assumes that humans will do dumb things and try to catch the errors. Hospital systems notoriously rely on doctors and nurses being perfect at every moment and then wonder why there are so many errors made.
Even airlines aren’t that stupid.
Additional:
Note that it is a “horror report” – despite involving less than 0.03% of hospital treatments.
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