Placing the practice of medicine in perspective while that mistakes are not isolated During the process


Journal of Kidney Treatment and Diagnosis is a peer-reviewed Journal, encourages on-going international research and information exchange through publication of latest advances on all aspects of Kidney Treatment and Diagnosis.

Some physicians recognize that adverse outcomes from errors usually do not happen because of an isolated error and actually reflect system problems. This concept is often referred to as the Swiss Cheese Model. This is the concept that there are layers of protection for clinicians and patients to prevent mistakes from occurring. Therefore, even if a doctor or nurse makes a small error (e.g. incorrect dose of drug written on a drug chart by doctor), this is picked up before it actually affects patient care (e.g. pharmacist checks the drug chart and rectifies the error). Such mechanisms include: Practical alterations (e.g.-medications that cannot be given through IV, are fitted with tubing which means they cannot be linked to an IV even if a clinician makes a mistake and tries to), systematic safety processes (e.g. all patients must have a Water low score assessment and falls assessment completed on admission), and training programmes/continuing professional development courses  are measures that may be put in place.

There may be several breakdowns in processes to allow one adverse outcome. In addition, errors are more common when other demands compete for a physician's attention. However, placing too much blame on the system may not be constructive.

Placing the practice of medicine in perspective

Essayists imply that the potential to make mistakes is part of what makes being a physician rewarding and without this potential the rewards of medical practice would be diminished. Laurence states that "Everybody dies, you and all of your patients. All relationships end. Would you want it any other way Don't take it personally Seder states " if I left medicine, I would mourn its loss as I've mourned the passage of my poetry. On a daily basis, it is both a privilege and a joy to have the trust of patients and their families and the camaraderie of peers. There is no challenge to make your blood race like that of a difficult case, no mind game as rigorous as the challenging differential diagnosis, and though the stakes are high, so are the rewards.

We will be looking forward to hearing a positive response from you soon.

With Regards,
John Robert                              
Managing Editor
Journal of Kidney Treatment and Diagnosis