The first area we discussed in our workshop was the need for developing protocols that are clear and unambiguous for various aspects of diabetes care,such as adequate testing for diabetes. Many people who have diabetes are admitted to a hospital and leave without a diagnosis of diabetes being made, and their outcomes are much worse if the diabetes is not treated.
The second system flaw that we identified is failure to screen patients with diabetes for coronary heart disease (CHD). Frequently, diabetic patients leave the hospital without being properly screened for CHD, and then, when they have an apparently innocuous procedure, they have a cardiac event—evensudden death—because of the stress of the procedure.
Another mistake that is sometimes made is that insulin is inadvertently withheld when patients are hospitalized for a surgical or medical procedure. As a result, they may even develop ketoacidosis while in the hospital. We reported on
two deaths that occurred as a result. That is unconscionable. It’s an extreme example of what can happen when peopledon’t communicate with each other.
In hospitals, communication between the different departments is often poor. The surgeon is the unquestioned chief in one area, the anesthesiologist in another. When a simple mistake occurs in such a situation, it may not be corrected because no one is empowered to question the decision of the person in charge.
