Decoding Health Care
Part 28: Medical errors and medical malpractice part one
Doctors do not like to talk about medical errors. A big reason is fear of being sued. But that is not the only reason. Most physicians view medical errors as personal failures. Throughout their training physicians are held to an impossible standard of perfection, and when they fall short they feel guilt and inadequacy. This is of course foolish. Doctors are human, and so imperfect and fallible. Mistakes are a part of life. But we should attempt to minimize mistakes and we can probably agree that some mistakes should never happen. And we should concede that all bad health outcomes are not the result of medical errors.
The issue with medical mistakes really came into focus with the Institute of Medicine publication in 1999, “To Err Is Human” (To Err is Human: Building a Safer Health System - PubMed). This report stated that close to 100,000 deaths each year, a number larger than deaths attributable to breast cancer or AIDS, were due to medical errors. And that a lot of these deaths were avoidable. The authors argued that there were clear shortcomings in the processes of care that could and should be fixed. The issue was not necessarily with doctors, it was with systems.
This report caused a stir in medicine. Disregard the fact that the methodology used in calculating the number of deaths was simplistic and certainly flawed (in fact, the number is likely much higher than the authors stated). But when I saw the authors’ recommendations I was less than impressed. The recommendations included:
1. Study the problem more.
2. Create an error reporting system.
3. Get professional societies involved.
4. Create a culture of safety.
These kind of platitudes are what most of us have come to expect whenever a panel of experts convenes to achieve consensus around how to fix a problem. There are no concrete suggestions. How could anybody disagree?
Boy was I wrong about how this report might impact medicine. A recent Health Affairs article summarized 20 years of innovation that followed the IOM report (Two Decades Since <italic>To Err Is Human</italic>: An Assessment Of Progress And Emerging Priorities In Patient Safety | Health Affairs). The IOM report energized the safety community.
One major mechanism of safety improvement was the adoption of standardized processes of care to reduce medical errors. It was well known that bad things could happen to patients in the hospital. Central venous catheters could get infected. Patients with urinary catheters got infections. Patients fell. Patients on ventilators got pneumonia. For a long time these adverse patient outcomes were treated with the general sentiment that “shit happens”. Turns out that by paying attention to detail, all of these could be reduced significantly.
Nowhere was this more true than in the operating room. Wrong site/wrong side surgery and retained sponges and surgical instruments were long dreaded errors in the OR. The way to solve this problem was to take a page from the airline industry. Next time you are getting on a plane, take a look in the cockpit and try to identify what the pilot and co-pilot are doing. They are running through a safety checklist. Lots of times you can also see the pilot on the tarmac walking around the plane and inspecting the underside. In each case, the crew is formally assessing the safety of that plane by completing a standardized checklist. Checklists were adopted in the 1980’s in commercial aviation and with them the number of airplane accidents dropped dramatically.
This approach was brought to the operating room by Peter Pronovost and Marty Makary at Johns Hopkins and Atul Gawande at Brigham and Women’s Hospital. The story of how it was done is beautifully told in Gawande’s book “The Checklist Manifesto”. He details how this was initially met with skepticism and resistance. The old guard just thought it was window dressing, that it wouldn’t make a bit of difference. But over time, even the most diehard resistance was overcome.
This is just the way we do things now. And the process isn’t confined to the OR. I am going to have some surgery in the near future. I needed to get pre-op testing so I went to the local medical arts building affiliated with the hospital where the procedure is going to be done. At check-in, my name and birth date were verified numerous times as was the planned surgery as well as the ordered testing. I was given an identifying wrist band. At each of my test stops, including CT, the lab, and EKG, my name and birthdate were verified numerous times and my wrist band was scanned. The tests to be performed as well as my planned procedure were verified as well. This was all done as a matter of routine. If I were grading them, I’d give them an A.
Medicare has decided that if you adopt these processes the likelihood of a medical error will be low. If you suffer one of these medical errors, something must not have been done right. And they have put their money where their mouth is. Since 2008, when a hospitalized patient suffers these complications, Medicare will not reimburse the hospital for care that is delivered to treat them. Ouch.
With the widespread adoption of the electronic medical record and particularly e-prescribing, another major opportunity has been identified. Medication errors were common. There were a lot of reasons. Clerical errors. Lousy doctor hand writing. Missed drug interactions or allergies. Dosing errors. When I started in oncology, there was no e-prescribing. Chemotherapy ordering involved writing out a series of administration instructions for the pharmacist and chemotherapy nurse. Dosing of the chemotherapy drug involved use of a slide-rule like apparatus called a body surface area calculator, and then filling in the blanks. The many potential steps at which errors might be introduced should be obvious. And errors did occur.
E-prescribing fixed a lot of that. In my post on medical education I discussed the Libby Zion case where a fatal drug interaction wasn’t recognized. The likelihood of this occurring with e-prescribing is vanishingly small. Prescribing errors still occur but they are nowhere near as common (Evaluation of the effectiveness of electronic prescription in reducing medical and medical errors (systematic review study) - PMC).
We are in a much better place when it comes to medical errors. It is very hard to quantitate how much better. But there is still a lot of work to be done. For one thing, a lot of the safety focus has been in the hospital setting whereas most medical care occurs in the outpatient setting. This shift in focus needs to occur.
Another major opportunity to reduce medical errors that has not yet received enough attention is diagnostic errors. What if the CT scan or mammogram was misread? What if the pathologist got it wrong? This area has been identified as a major opportunity for information technology and artificial intelligence. There are lots of companies working on ways to improve diagnostic accuracy. Images can be digitized and compared to data sets of known clinical accuracy. As time goes on we should get better and better with these diagnostic tests. At what point physician interpretation becomes superfluous is a question we may need to face.
No doctor or health system wants medical errors to occur. Sometimes they do. Sometimes doctors just make mistakes. And sometimes patients have a bad outcome even if everything is done right. It seems somehow callous to call this bad luck; but medicine is an imperfect science and things can go wrong.
In part two, we will discuss the dreaded topic of medical malpractice.