Fixing Medical Err-ERs


The NYT has an Op-Ed by a former head of the National Transportation Safety Board talking about reforming the health care system and reducing medical errors. He cites the To Err Is Human Institute of Medicine report suggesting 98,000 annual deaths and billions of dollars due to medical errors, and notes:

What makes the problem all the more frustrating is that we could address it with little cost to the American taxpayer. Because American medicine accepts error as an inevitable consequence of treatment, our hospitals, insurers and government do little to respond to unnecessary deaths. If we are to address the problem in a serious manner, we must first change this culture.

He then goes on to start talking about “Hospital-acquired infections, for instance, affect millions of Americans each year,” and loses me, after comparing “our roads, rails and skies” to our medical system.

Don’t get me wrong. I’m the first to admit that the medical system makes errors. “To err is human,” and I can’t help but agree. As physicians we’re doing our best to simplify incredibly complex biological systems down to a level that our brains can comprehend and try to evaluate and treat. We also have good days and bad ones, and on occasion even let our emotions affect our logical, rational, objective decision making. Damn right I accept errors as a consequence of treatment. I don’t like them; I would like to minimize them, but I accept them. Everything in life is risk-benefit.

So there’s point number one: we’re human, and by definition, flawed. Doctors are not gods, do not know everything, do not have all the answers. And we will, sadly, make medical errors.

Number two: what’s a medical error? The report this whole thing is based on says there’s a bunch of types, but how many are really fixable?

  • Diagnostic Error. ex: Error or delay in diagnosis
  • Treatment Error. ex: Error in the dose or method of using a drug
  • Preventive Error. ex: Failure to provide prophylactic treatment
  • Other Errors. ex: Failure of communication, Equipment failure

Medication errors are often the big, obvious, low-hanging fruit. It’s why we can’t write “MgSO4″ for magnesium, because our crappy handwriting sometimes was interpreted as “morphine sulfate.” It’s things like the Dennis Quaid heparin saga when his neonate twins were given adult doses of heparin (adult dose heparin should probably be a different size or color and should probably never be available on a pediatric floor, duh). But other errors are much harder to fix, and probably come with even more unintended consequences (see #4).

Number three: can we really simplify the medical system down to levels that they can in the transportation industry? Sure, there are plenty of things that can go wrong with a plane, internal and external factors like engine malfunctions and torrential rains, but I feel like there’s many more that can go wrong with humans–not just the patient, but also the multiple humans taking care of the patient. Yes, there’s definitely obvious areas like central line placement checklists and the anesthesia world learning from aviation standards and checklists, but I can’t imagine any other place being more challenging than the barely-controlled chaos of a busy emergency department.

And finally for the ultimate problem in de-bugging medical errors: unintended consequences. This is the art of public policy where things often go awry. Take, for example, “medical errors” of Medicare’s “never events”:

  • No Serious Disability from Falls. Lofty goal, sounds great, right? But what do we do with the elderly demented patient who continually gets out of bed? Restrain them, sedate them, or have someone watch them 24/7? Falls are an awful thing, and I’ve seen first hand the consequences, but there are plenty of consequences to preventing every single one of them in every single patient, too. What about the young patient who is told not to walk on their broken leg, but still believes they’re strong enough? Do we sedate or restrain everyone who has the potential to fall?
  • No Catheter-Associated Urinary Tract Infections. Again, sounds good, but can we really get this down to zero in the intubated, diabetic, HIV, cancer patient in CHF who needs monitoring of their I’s and O’s? What’s the solution to this “never event,” cipro-coated catheters? (And then for the now-cipro-resistant bugs we’ve just created?)
  • No DVT/PE after Orthopedic Procedures. So the hypercoaguable patients just won’t get orthopedic procedures, because orthopods just won’t touch them anymore, for risk of triggering a “never event,” which the hospital won’t pay for.

I could go on, but you get the point. These events should be “almost-never events.” Medicare has plenty of data for all this stuff; they should come up with a reasonable standard that every hospital should have to meet. “Average percentage of UTIs from foleys today in a 500 bed hospital: 3%. All similar hospitals must all now be under 3%.”

In nowhere are these tradeoffs more apparent than in the Emergency Department, where everything is probably just a liiiittle more error prone, with multiple sick patients, little to no medical history on patients, and a limited time frame in which to act: diagnose, treat, and dispo patients. Antibiotics for pneumonia in 6 hours? Great for the obvious febrile coughing patient with infiltrate. But add anything else in there, and the story gets murky, while we still get judged on our “quality.” To give or not to give, which is the medical error?

I’m all for Jim Hall coming to visit my Emergency Department to figure out how I can do better for my patients, as long as he realizes that there’s no free lunch, everything has a risk and a benefit, and that at some point, in medicine minimizing one error just maximizes another.

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  1. #1 by Chris McCoy - July 30th, 2009 at 20:37

    Great points, Graham. We certainly can learn from the aviation and transportation safety arena, but as long as humans are not mass produced in assembly lines, we’ll be working with incredibly complex biological system with more variables and inter-individual differences than we can mentally grasp.
    Plus, we’re morally obligated to work with everyone who comes for our help … and we’re can’t write them off as a total loss if they are broken beyond repair, or send them back to the factory for a replacement, etc. We should always strive to do better, but we should also recognize when working to prevent one problem (like in-hospital falls) will worsen another (delirium from sedation).

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