Comment by intertextuality | Hacker News Reader

Comment by intertextuality | Hacker News Reader

intertextuality

I work on software related to medical drilling. Nurses run through simulations (mostly a situation where something has gone wrong) and get graded.

It baffled me to learn that this is NOT the norm at hospitals. Due to the stress of a situation-gone-awry and inexperience, some horrific things can happen.[0][1] In some situations you may only have a few minutes to enact corrective procedures. In any case without checklists (and without experience from running routine simulations) it's very easy to make mistakes or forget what to do.

I thought the checklists themselves were standard but it appears not...? The more I learn about hospitals' operating practice the more wary I become. I have no idea why hospitals aren't like the aviation industry and have checklists and expiring certifications. (Or maybe I heard wrong and I'm just completely wrong here.)

[0]: https://www.telegraph.co.uk/news/2018/05/10/premature-baby-d...

[1]: https://www.nbcbayarea.com/news/local/Dental-Anesthesia-Unde...

> Mead said the principal risk is a patient’s airway. He explained that a child’s breathing tube can collapse without warning under sedation.

> “It happens instantaneously,” he said. “You have maybe half a minute to make critical decisions about how you're going to manage that child's airway. You can't do that if you don't have somebody competent there helping you.”

I was part of a start-up developing checklist for high risk pregnancies. The checklists were developed by some of the best doctors in the country, who had already proved the worth of using checklists in their own practice. Even with all of that, we had unending push back from every single hospital we talked to. Eventually it killed the company because deals could not be closed. I still hear of hospitals saying they want checklists, and they keep saying that until they see one, and then they don't want it anymore.

Also, it wasn't a cost issue. The package was pretty cheap all told. The push back was in the "system getting in the way"...which was kind of the point unfortunately.

Atul Gawande talks about the importance of developing checklists collaboratively with the people who will use them as opposed to imposing them top down.

Many procedures in hospitals are checklist-driven. Peter Pronovost had an early, high-impact publication on the topic of bloodstream infection prevention with checklists: https://www.nejm.org/doi/full/10.1056/NEJMoa061115

I was surprised too, I worked on software for Surgery checklists a decade ago and thought it was standard practice and that only our digitization of it was new, the effects of a checklist have been known for quite a while now. The software I worked on would track every instrument and screw taken into a theatre (using hand scanners), the doctor would have his list of steps for the procedure and the equipment necessary, standard emergency packages were available for the exceptions, etc. It's not just for the direct patients either, some disease can survive instrument sterilization so knowing who else they've been used on can be important.

In the aviation industry pilots rarely get sued personally. IMO, the issue is more about legal system than it is about the medical one.

The solution may be found in the legal system and its corresponding arm, the malpractice insurers, if both were to mandate a minimal standard of care including the use of checklists.

I agree with the first part, but not with your conclusion.

There is way too much litigation. Hospitals and staff are using defensive legal strategies-- obscuring docs, discouraging internal (written) investigation, delaying urgent treatment with unneeded consultation (to get more signatures on a decision).

IMO, there should be legal protection against malpractice lawsuits. Increasing the attack surface will not help with the core problem:

Doctors are over-worked, they are human and they make mistakes. The solution is to either enforce work conditions for doctors (and people die) or accept those mistakes (and people don't get money when they are on the wrong side of statistics)

So who else should be untouchable?

What purpose does suing anyone for anything serve?

I don’t see too many doctors demanding to become employees (with far less personal liability) instead of independent contractors as they usually are. Getting the best of both worlds is asking for a lot.

I didn't mean to say that they should be "untouchable". Only that they should be given some protection for some very human, systematic, (unavoidable?,) mitigating factors

In the aviation industry, lawsuits aren't necessary. If a pilot makes a serious enough mistake, he dies. If we executed doctors when their patients died, lawsuits would be the least of their concerns.

Because they're dead? Surgeons don't have that much of their own skin in the game...

If anything that sounds like a great reason for a doctor to use an industry standard checklist. "See exhibit A, documenting that my client followed the proper procedures". Not that that necessarily sounds great for patients with legitimate suits but for doctors it sounds useful.

Yep, so they'll fill the checklist beforehand just to make sure they're covered...

If a pilot makes a mistake, he'll either die or lose his licence. Either way, his life is ruined.

No it's not. Career =/= life.

Most pilots would feel pretty bad if they survived a crash that was fatal to their passengers.

> If a pilot makes a mistake, he'll either die or lose his licence.

I have a private pilot license. This is not true at our level, and is very often not the case at the big companies. Everyone makes mistakes; firing all the mistake-makers would not end well.

One of the reasons aviation is so safe (excluding corporate coverups like what happened a couple of times with Boeing) is that there is an emphasis on learning and making sure that mistakes never happen again - to you or to other pilots.

One of the exams for the Light Aircraft Pilot License for sailplanes in Europe has the multiple-choice question "Why is safety improved by submitting an official report of safety-related incidents?", where one option is "because then we can revoke the licenses of unsafe pilots", and another is "because then we can collectively learn from dangerous situations". Spoiler alert, the latter is the correct answer.

I can't speak for professional aviation, but I would be very surprised if the safety ethos isn't similar. Ruining a career after a mistake only leads to covering up mistakes. Why the hell is this a systemic problem at all? It's obvious it won't work.

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