James Bagian on medical error
Kathryn Schulz has a wonderful Q&A with James Bagian, director of the VA national center for patient safety, at the Slate blog "The Wrong Stuff". Read it all, but I especially enjoyed his thoughts on blame, punishment, and the perverse incentives that can be introduced by public disclosure.
Kathryn Schulz is the author of the book, Being Wrong: Adventures in the Margin of Error. I haven't read it, but I think I'll check it out.
Thanks for posting this, Dan. I had the opportunity to hear Dr. Bajian speak at our hospital a few years ago and found his talk riveting.
ReplyDeleteThe theme that runs through the interview here is honesty. He says "You can never make the probability of failure zero." He he notes that airlines are prohibited to advertise their safety records for fear of providing an incentive to not report. Yet APIC and others continue to blather on about "getting to zero." And I have argued all along it's an inherently dishonest argument. Maybe someday we'll catch up with the aviation industry.