As the Harvard philosopher George Santayana famously remarked, “Those who cannot remember the past are condemned to repeat it.” Now Crico/RMF, the insurance company which provides medical malpractice coverage for Harvard-affiliated hospitals, is attempting to learn from past medical mistakes to avoid repeating them.
The results are a white paper on emergency room medical malpractice entitled, “Optimizing Physician-Nurse Communication in the Emergency Department: Strategies For Minimizing Diagnosis-related Errors.” (H/t WSJ Health Blog).
Its findings? Breakdowns in communications between ER docs and ER nurses are the main source of avoidable medical errors in the ER.
To give you a flavor of the types of errors that we are talking about, the report cites an 18-year old who showed up in the ER with fever, chills and mottled skin. The nurse noted the mottled skin – a symptom of a dangerous blood infection – but the doctor never learned of the mottled skin, leading him to discharge the patient with Tylenol, only for the patient to die subsequently of shock and sepsis caused by the blood infection.
If improving communication between doctors and nurses is the key to avoiding medical malpractice in the Emergency Room, it seems to me that medicine should, once again, be borrowing a page from aviation safety methods – such as the “first name rule” – that aviation industry implemented to improve communications between pilots and the rest of the crew. But the Crico/RMF white paper doesn’t float any proposals derived from the principles of aviation safety.
Instead, it talks about “Team Training/Simulation” and professional development for nurses, among other things.
If medicine were willing to learn from the aviation industry, I might feel as comfortable in the ER as I do flying on a 747.

This blog in maintained by the Boston medical malpractice lawyers at The Law Office of Alan H. Crede, P.C.