Coroner Talk™ | Death Investigation Training | Police and Law Enforcement

This Episode is part 2 of last weeks conversation about medical errors being the third leading cause of death in the United States. This week I set down with medical expert  Shawn Parcells of National Autopsy Serivices and discussed  a few actualcases concerning medical errors.

Medical error has been defined as an unintended act (either of omission or commission) or one that does not achieve its intended outcome,3 the failure of a planned action to be completed as intended (an error of execution), the use of a wrong plan to achieve an aim (an error of planning),4 or a deviation from the process of care that may or may not cause harm to the patient.5 Patient harm from medical error can occur at the individual or system level. The taxonomy of errors is expanding to better categorize preventable factors and events.6 We focus on preventable lethal events to highlight the scale of potential for improvement.   (bmj.com article portion)

Medical error is the third leading cause of death in the United States, after heart disease and cancer, according to findings published today in British Medical Journal.As such, medical errors should be a top priority for research and resources, say authors Martin Makary, MD, MPH, professor of surgery, and research fellow Michael Daniel, from Johns Hopkins University School of Medicine in Baltimore, Maryland. But accurate, transparent information about errors is not captured on death certificates, which are the documents the Centers for Disease Control and Prevention (CDC) uses for ranking causes of death and setting health priorities. Death certificates depend on International Classification of Diseases (ICD) codes for cause of death, so causes such as human and system errors are not recorded on them. And it’s not just the US. According to the World Health Organization, 117 countries code their mortality statistics using the ICD system as the primary health status indicator. The authors call for better reporting to help capture the scale of the problem and create strategies for reducing it.

Cancer and Heart Disease Get the Attention

“Top-ranked causes of death as reported by the CDC inform our country’s research funding and public health priorities,” Dr Makary said in an university press release. “Right now, cancer and heart disease get a ton of attention, but since medical errors don’t appear on the list, the problem doesn’t get the funding and attention it deserves.” He adds: “Incidence rates for deaths directly attributable to medical care gone awry haven’t been recognized in any standardized method for collecting national statistics. The medical coding system was designed to maximize billing for physician services, not to collect national health statistics, as it is currently being used.” The researchers examined four studies that analyzed medical death rate data from 2000 to 2008. Then, using hospital admission rates from 2013, they extrapolated that, based on 35,416,020 hospitalizations, 251,454 deaths stemmed from a medical error. That number of deaths translates to 9.5% of all deaths each year in the US — and puts medical error above the previous third-leading cause, respiratory disease. In 2013, 611,105 people died of heart disease, 584,881 died of cancer, and 149,205 died of chronic respiratory disease, according to the CDC. The new estimates are considerably higher than those in the 1999 Institute of Medicine report “To Err Is Human.” However, the authors note that the data used for that report “is limited and outdated.

Medical error has been defined as an unintended act (either of omission or commission) or one that does not achieve its intended outcome,3 the failure of a planned action to be completed as intended (an error of execution), the use of a wrong plan to achieve an aim (an error of planning),4 or a deviation from the process of care that may or may not cause harm to the patient.5 Patient harm from medical error can occur at the individual or system level. The taxonomy of errors is expanding to better categorize preventable factors and events.6 We focus on preventable lethal events to highlight the scale of potential for improvement.   (bmj.com article portion)

Medical error is the third leading cause of death in the United States, after heart disease and cancer, according to findings published today in British Medical Journal.As such, medical errors should be a top priority for research and resources, say authors Martin Makary, MD, MPH, professor of surgery, and research fellow Michael Daniel, from Johns Hopkins University School of Medicine in Baltimore, Maryland. But accurate, transparent information about errors is not captured on death certificates, which are the documents the Centers for Disease Control and Prevention (CDC) uses for ranking causes of death and setting health priorities. Death certificates depend on International Classification of Diseases (ICD) codes for cause of death, so causes such as human and system errors are not recorded on them. And it’s not just the US. According to the World Health Organization, 117 countries code their mortality statistics using the ICD system as the primary health status indicator. The authors call for better reporting to help capture the scale of the problem and create strategies for reducing it.

Cancer and Heart Disease Get the Attention

“Top-ranked causes of death as reported by the CDC inform our country’s research funding and public health priorities,” Dr Makary said in an university press release. “Right now, cancer and heart disease get a ton of attention, but since medical errors don’t appear on the list, the problem doesn’t get the funding and attention it deserves.” He adds: “Incidence rates for deaths directly attributable to medical care gone awry haven’t been recognized in any standardized method for collecting national statistics. The medical coding system was designed to maximize billing for physician services, not to collect national health statistics, as it is currently being used.” The researchers examined four studies that analyzed medical death rate data from 2000 to 2008. Then, using hospital admission rates from 2013, they extrapolated that, based on 35,416,020 hospitalizations, 251,454 deaths stemmed from a medical error. That number of deaths translates to 9.5% of all deaths each year in the US — and puts medical error above the previous third-leading cause, respiratory disease. In 2013, 611,105 people died of heart disease, 584,881 died of cancer, and 149,205 died of chronic respiratory disease, according to the CDC. The new estimates are considerably higher than those in the 1999 Institute of Medicine report “To Err Is Human.” However, the authors note that the data used for that report “is limited and outdated.”

Strategies for Change

The authors suggest several changes, including making errors more visible so their effects can be understood. Often, discussions about prevention occur in limited and confidential forums, such as a department’s morbidity and mortalit...

In the real world, not everything goes well, not everyone is happy, there is always bad news as well as good, troubled waters as well as smooth. Very few investigators  fail because of their inability to deal with success. Typically, failure in this industry results from an inability to deal with problems. Conflict  resolution within the police and investigative agencies  can be very difficult.  Some action, even if that is deliberate non action, must take place. 

In this episode I share a portion of training around the topic of conflict between peers and associated agencies.  Below are some quick tips we covered in the training.

Four  Basic Principles of Conflict

1. Conflict is normal and not all conflict is bad.

Some conflict is creative and has real positive uses. Sometimes its just a matter of differing life styles or opinions. Resolved properly these can be very use full

2. Good conflict may deepen superficial relationships

Many times relationships are very shallow and people never get close enough to ever even have a conflict.  Very often when a disagreement occurs the relationship between the two parties deepen, because they have come to know each other better. 

3. Personal growth often occurs through dissonance

Dissonance simply means lack of agreement.   Growth often occurs because the social  turbulence causes people to look for  resolution therefore resulting in personal growth.  Within  the public service community and among men and women of goodwill, conflict is common, not always bad, and can have positive outcomes. 

4. A model of advocacy may appear to be contention when it is not really  conflict

This can be an effective way to reach decisions.  If a group in a room brings together their own  passionate opinions and each expresses  them strongly, a disagreement can result. But done correctly and in humility the end can result in a balanced and successfully outcome and decision.

Five Basic Causes of Conflict

1. Conflict is frequently because of  unmatched expectations

These can lead to disappointment which leads to loss of confidence, and can arise from misunderstandings.  A different set of expectations of a leader, program, style, etc is a certain recipe for conflict

2. Conflict is caused by the mounting number of buried hurts, slights, and insults.

These hurts are often times collected up and saved. Burying feelings , disappointments, personal injuries, etc is  a  deadly illness in the public service arena. It is very unhealthy to bury your hurts. They will come out someday and in a big way. Many times conflict between two people in an agency is from a gradual buildup of hurt and disappointment.

3. A major cause of conflict is unexpressed fears.   (and jealousy)

People may find themselves resisting others because of fears that may have never been expressed. It is easy to become paranoid. It is easy to be fearful about what might happen in situations involving other co-workers or related agencies. If these fears are never expressed, they can never be countered, they can never be checked out, so they can never be resolved.

4. Competition for limited resources can cause conflict.

There is never enough money, time, or attention in the work of public service and government.  Leaders are many times placed in a situation where there is competition for  money and resources. The leader must respond by constantly reassuring people in an atmosphere of fairness so that conflict won’t occur. If someone gets the feeling that they  are not valued as highly as someone else, conflict will occur.

5. Conflict escalates in a hostile and failing environment.

A psychological study shows that if people or animals are put in situations in which pain is delivered and discomfort is created,

“Our medicolegal death investigators are 50 percent detectives and the other 50 percent of the job they’re social workers. In one minute they’re investigating a horrific homicide and the next minute they’re notifying the family members of the victim of that homicide. The family may be embracing them and crying on their shoulder. It takes a very unique group of people to be able to flip that switch.” – John Fudenberg – Las Vegas Coroner.

John Fudenberg, is the Coroner of  Clark County Nevada, home to the world known  ‘sin city’, Las Vegas. The Clark County Coroners office is a hybrid office, being a coroners  office but housing a full pathology department.  Currently there are two Coroner Investigative Forensic Supervisors, 16 full-time Coroner Investigators and five part-time investigators that respond throughout the Las Vegas valley. There are also three part-time investigators that handle the southern portion of Clark County, which encompasses the Laughlin and Searchlight areas, and three part-time investigators that handle the northern County region.

Clark County is also unique in that John Fudenberg is the immediate past President of the International Coroners and Medical Examiners Association, and still sits on that board.  Also the chief Medicolegal investigator for Clark County, David Mills, is the immediate past President of   The American Board of Medicolegal Death Investigators.  (ABMDI).  These prestigious positions placed Clark County Coroners office in a position of authority when it comes to speaking into the medicolegal death investigation field.

Part Time and Reserve Investigators

Another unique function os the Clark County Coroners office is their volunteer reserve program for investigators.  These men and women join the office and complete a training program to prepare them to work with full time investigators and serve as a ‘farm team’ for filling future  investigator openings .

In this episode

In this episode I talk with the ‘Las Vegas’ Coroner John Fudenberg and Assistant Coroner Paul Parker about the unique positioning of their office.  We also talk about the  recommendations for the medicolegal field by 2020, as well as where John sees the future of Coroners in America  going.   These and many other topics are discussed.

 

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