Portal de Periódicos da CAPES

Transparency in Health Care

2008; Elsevier BV; Volume: 133; Issue: 1 Linguagem: Inglês

10.1378/chest.07-2100

1931-3543

Joseph G. Murphy, William F. Dunn,

Blood Pressure and Hypertension Studies

The patient bore his acute sufferings with fortitude and perfect resignation to the Divine will, while as the night advanced it became evident that he was sinking, and he seemed fully aware that “his hour was nigh.” He inquired the time, and was answered a few minutes to ten. He spoke no more—the hand of death was on him, and he was conscious that “his hour was come.” With surprising self-possession he prepared to die. Composing his form at length, and folding his arms on his bosom, without a sigh, without a groan, the Father of his Country died. No pang or struggle told when the noble spirit took its noiseless flight; while so tranquil appeared the manly features in the repose of death, that some moments had passed ere those around could believe that the patriarch was no more.George Washington Custis, Recollections and Private Memoirs of Washington1EyeWitness to history.com The death of George Washington, 1799.Available at: www.eyewitnesstohistory.com/washington.htmGoogle ScholarGeorge Washington, America's first president, died due to a combination of asphyxiation (probably due to bacterial epiglottitis secondary to Haemophilus influenzae or Corynebacterium diphtheriae infection) and physician error that led to hypovolemic shock due to exsanguinating blood loss following therapeutic bloodletting. The total quantity of blood removed from George Washington by bloodletting was estimated to amount to between 82 and 126 fluid ounces, or 2.4 to 3.75 L, drawn over a period of 9 to 10 h on Saturday, December 14, 1799.2Vadakan VV The asphyxiating and exsanguinating death of president George Washington. In: The Permanente Journal.Available at: xnet.kp.org/permanentejournal/spring04/time.htmlGoogle Scholar Washington had an estimated blood volume of approximately 7 L based on his height of 6 feet 3 inches and weight of 230 lb. Exsanguination of 30 to 50% of a patient's blood volume over a period of approximately 10 h almost certainly led to hypovolemia, hypotension, and shock. While some of the details of Washington's death have been lost in the mists of time, physician mismanagement by well-intentioned doctors almost certainly contributed to his death. The above quotation illustrates that, unfortunately, medical errors have always been part of medical practice; can happen to anybody, including presidents; and are frequently covered up. In the case of George Washington, the cover up lasted for > 100 years until the seminal paper by Bricknell in 1903.2Vadakan VV The asphyxiating and exsanguinating death of president George Washington. In: The Permanente Journal.Available at: xnet.kp.org/permanentejournal/spring04/time.htmlGoogle ScholarIf truth be told, nobody really knows the extent of medical errors in the practice of health care. Various estimates have put the number of deaths due to medical errors in the United States at 50,000 to 100,000 patients per year or, more graphically, as many as a jumbo jet full of people crashing each and every day. Medical errors are estimated to be the fifth-leading cause of death in the United States, exceeding the number of deaths due to motor vehicle accidents. The estimated cost to the health-care system is over $25 billion annually. While authorities may quibble over the details, there is no doubt that medical errors are a major problem within our health-care system.It is a great honor and pleasure for us to edit a new regular column on transparency in health care for CHEST. The focus of this column is broad and will include studies relevant to patient safety, commentaries, illustrative case reports, and case series that focus on patient safety, medical errors, and issues of transparency in health care. In this issue, we begin the series by publishing two articles on patient safety: one a commentary on the importance of transparency in health care from our senior Mayo colleagues, Drs. Swensen and Cortese,3Swensen SJ Cortese DA Transparency and the “end result idea.”.Chest. 2008; 133: 233-235Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar and a case report by Boseila et al4Granetzny A Holtbecker N Thomas H et al.Misinterpretation of a pulmonary GI anastomosis stapler line as a retained foreign body.Chest. 2008; 133: 281-283Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar from Duisberg, Germany, of a medical error due to an incorrect diagnosis of an intrathoracic foreign body that turned out to be a GIA stapler line (US Surgical/Tyco Healthcare; Norwalk, CT) from a previous lung resection. Transparency in health care is such a fundamental part of quality health care that it is fitting that the lead article for this column addresses this important issue. Surely we cannot advance the science and art of medicine if we are not honest about our results in an open and reflective manner. The second article, a case report, illustrates several important concepts in medical error prevention. Medical errors often result from a series of events—the error chain—that come together in an unfortunate sequence that leads to a poor outcome. A single break in the sequence of events can often prevent the medical error. The authors simulated the error following the second thoracotomy by placing a GI anastomosis stapler line on the patient's skin and repeating the chest radiograph.When approaching an issue as sensitive as medical errors, it is important to have some ground rules. We wish to applaud the honesty, integrity, and courage of our authors who present issues of medical error in hopes of improving health care in general.We primarily seek papers that have studied an aspect of patient safety in an organized and scientific manner. Case series and possibly case reports may be acceptable if they include specific, generally applicable clinical teaching points. We also encourage thoughtful commentaries on patient safety and transparency in health care. With respect to word and reference limits and formatting of manuscripts, please follow our Instructions to Authors for Case Reports, Commentaries, and consider reviews as a Special Feature. CHEST, as an international medical journal, welcomes original submissions from outside the United States that advance or illuminate medical science or practice, or that educate or entertain the readers of the journal. The patient bore his acute sufferings with fortitude and perfect resignation to the Divine will, while as the night advanced it became evident that he was sinking, and he seemed fully aware that “his hour was nigh.” He inquired the time, and was answered a few minutes to ten. He spoke no more—the hand of death was on him, and he was conscious that “his hour was come.” With surprising self-possession he prepared to die. Composing his form at length, and folding his arms on his bosom, without a sigh, without a groan, the Father of his Country died. No pang or struggle told when the noble spirit took its noiseless flight; while so tranquil appeared the manly features in the repose of death, that some moments had passed ere those around could believe that the patriarch was no more. George Washington Custis, Recollections and Private Memoirs of Washington1EyeWitness to history.com The death of George Washington, 1799.Available at: www.eyewitnesstohistory.com/washington.htmGoogle Scholar George Washington, America's first president, died due to a combination of asphyxiation (probably due to bacterial epiglottitis secondary to Haemophilus influenzae or Corynebacterium diphtheriae infection) and physician error that led to hypovolemic shock due to exsanguinating blood loss following therapeutic bloodletting. The total quantity of blood removed from George Washington by bloodletting was estimated to amount to between 82 and 126 fluid ounces, or 2.4 to 3.75 L, drawn over a period of 9 to 10 h on Saturday, December 14, 1799.2Vadakan VV The asphyxiating and exsanguinating death of president George Washington. In: The Permanente Journal.Available at: xnet.kp.org/permanentejournal/spring04/time.htmlGoogle Scholar Washington had an estimated blood volume of approximately 7 L based on his height of 6 feet 3 inches and weight of 230 lb. Exsanguination of 30 to 50% of a patient's blood volume over a period of approximately 10 h almost certainly led to hypovolemia, hypotension, and shock. While some of the details of Washington's death have been lost in the mists of time, physician mismanagement by well-intentioned doctors almost certainly contributed to his death. The above quotation illustrates that, unfortunately, medical errors have always been part of medical practice; can happen to anybody, including presidents; and are frequently covered up. In the case of George Washington, the cover up lasted for > 100 years until the seminal paper by Bricknell in 1903.2Vadakan VV The asphyxiating and exsanguinating death of president George Washington. In: The Permanente Journal.Available at: xnet.kp.org/permanentejournal/spring04/time.htmlGoogle Scholar If truth be told, nobody really knows the extent of medical errors in the practice of health care. Various estimates have put the number of deaths due to medical errors in the United States at 50,000 to 100,000 patients per year or, more graphically, as many as a jumbo jet full of people crashing each and every day. Medical errors are estimated to be the fifth-leading cause of death in the United States, exceeding the number of deaths due to motor vehicle accidents. The estimated cost to the health-care system is over $25 billion annually. While authorities may quibble over the details, there is no doubt that medical errors are a major problem within our health-care system. It is a great honor and pleasure for us to edit a new regular column on transparency in health care for CHEST. The focus of this column is broad and will include studies relevant to patient safety, commentaries, illustrative case reports, and case series that focus on patient safety, medical errors, and issues of transparency in health care. In this issue, we begin the series by publishing two articles on patient safety: one a commentary on the importance of transparency in health care from our senior Mayo colleagues, Drs. Swensen and Cortese,3Swensen SJ Cortese DA Transparency and the “end result idea.”.Chest. 2008; 133: 233-235Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar and a case report by Boseila et al4Granetzny A Holtbecker N Thomas H et al.Misinterpretation of a pulmonary GI anastomosis stapler line as a retained foreign body.Chest. 2008; 133: 281-283Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar from Duisberg, Germany, of a medical error due to an incorrect diagnosis of an intrathoracic foreign body that turned out to be a GIA stapler line (US Surgical/Tyco Healthcare; Norwalk, CT) from a previous lung resection. Transparency in health care is such a fundamental part of quality health care that it is fitting that the lead article for this column addresses this important issue. Surely we cannot advance the science and art of medicine if we are not honest about our results in an open and reflective manner. The second article, a case report, illustrates several important concepts in medical error prevention. Medical errors often result from a series of events—the error chain—that come together in an unfortunate sequence that leads to a poor outcome. A single break in the sequence of events can often prevent the medical error. The authors simulated the error following the second thoracotomy by placing a GI anastomosis stapler line on the patient's skin and repeating the chest radiograph. When approaching an issue as sensitive as medical errors, it is important to have some ground rules. We wish to applaud the honesty, integrity, and courage of our authors who present issues of medical error in hopes of improving health care in general. We primarily seek papers that have studied an aspect of patient safety in an organized and scientific manner. Case series and possibly case reports may be acceptable if they include specific, generally applicable clinical teaching points. We also encourage thoughtful commentaries on patient safety and transparency in health care. With respect to word and reference limits and formatting of manuscripts, please follow our Instructions to Authors for Case Reports, Commentaries, and consider reviews as a Special Feature. CHEST, as an international medical journal, welcomes original submissions from outside the United States that advance or illuminate medical science or practice, or that educate or entertain the readers of the journal.