Dr. Brian Goldman's TEDTalk, "Doctor's Make Mistakes... Can We Talk About That?" has been viewed by more than half a million people. With candor and humor, this Canadian emergency room doctor and journalist describes how the kindly saying "to err is human" has not really applied to doctors. Yet all doctors make mistakes, which are inescapable. The problem is less the mistakes but that medical practice has become a culture of blame that is not just bad for doctors... it is bad for patients.
Dr. Goldman is not alone, nor is awareness of medical errors new. An Institute of Medicine report in 1999 estimated that approximately 100,000 people die each year in U.S. hospitals due to preventable medical mistakes. This led The Institute for Healthcare Improvement (IHI), in 2004, to launch its 100, 000 Lives Campaign across U.S. hospitals, which exceeded its life-saving goal in 18 months. It succeeded not by tarring and feathering doctors and nurses or by promoting malpractice litigation. It did so by measuring performance and making quality improvement a virtue to be rewarded.
Typical errors we patients and families are apt to suffer include: how a treatment is delivered (like wrong side surgery or the wrong dose of a medication), delays in responding to abnormal tests, failure to provide antibiotics during surgical procedures to prevent infection, and inadequate monitoring or follow-up of a patient's condition. Simple matters like hand washing in hospitals are woefully not followed, just as this simple procedure is ignored amongst everyone during flu season despite the pictures of hands under a faucet posted on walls everywhere.
The wonderful book The Checklist Manifesto: How To Get Things Right, by Dr. Atul Gawande, a Harvard surgeon and MacArthur Fellow, tells a remarkable story about a pre-surgical checklist he created with a multinational team for the World Health Organization that dramatically reduced postoperative infections (36 percent) and deaths (47 percent) in rich and poor nations in teaching and tent hospitals. What was so ironic was that Gawande thought he himself did not need this checklist until using it prevented a patient death when he was operating. Simple checklists have what engineers call a "forcing function," an inescapable path that reduces errors. Yet, still only a fraction of hospitals employ checklists of any sort, even though they have become standard fare in aviation and other precision and safety-oriented settings.
Checklists are only one way to prevent medical errors. Others include "redundant operations." When multiple people ask the same question (e.g., what's your birth date or which side of your body will have the operation?) the likelihood of a treatment error drops precipitously; when doctors have their orders checked by nurses and pharmacists their (human) errors are reduced. Technology is our friend when it comes to reducing errors: Physician order entry (POE), where doctors write prescriptions not on pads but into computer systems, reduces very common transcription errors by more than 80 percent. Other electronic medical record innovations include "decision support," a nice way of saying that the computer will ask the doctor if that dose or the use of a particular medication combined with another is safe, so that doctors have live-time support in managing the now vast amount of knowledge needed to practice medicine safely.
Yet another way to reduce errors is to better manage what is called "decision fatigue," where low mental energy from lack of sleep, low blood sugar, and ceaseless demands for decisions diminishes the mind's capacity to make good choices (Willpower: Rediscovering the Greatest Human Strength, Roy F. Baumeister and John Tierney, 2011). If you feel a bit overwhelmed when confronted by 40 different cereal brands in the grocery store, imagine what it must be like to manage the decisions needed for 40 people in a busy emergency room or doctor's office.
In the wake of an error, doctors and hospitals must also learn to apologize and lend support to families. The days of hiding behind lawyers are thankfully becoming a part of the past. In 2006, an unusual report emerged from the Harvard University Hospitals called When Things Go Wrong: Responding to Adverse Events. The report stated that:
Fears of malpractice liability, difficulties in communicating bad news, and confusion about causation and responsibility have long impeded comprehensive and bold initiatives designed to change the patient, family and clinician experience with medical error.
Error can be reduced and safety improved when "an institutional response ... focuses on rapid and open disclosure and emotional support to patients and families who experience serious incidents." In short, it is time to stop hiding errors and to say "I am sorry" when bad things happen. It is also time to support (not blame) and train doctors and nurses by establishing a medical culture of transparency and safety.
As patients and families, we cannot sit back and imagine all is well, that the doctor knows best. Like it or not, we must be vigilant and unstinting advocates for ourselves. We are responsible for giving clear and honest information about our habits and medical care, lest we not provide doctors the information they need to treat us safely. We must screw up our courage and ask questions when we don't understand or think that something is going awry. Writing down your questions and concerns before you meet with a doctor, who is surely pressed for time, helps optimize decision making and keeps you focused at a time when stress is high.
I am heartened by the dawn of what is called "patient-centered care." This is far more than a slogan; it is a deep and abiding commitment by caregivers to put the patient first, foremost, in a medical care system too often organized for the convenience of caregivers and administrators. There is something old fashioned yet ageless about designing a medical service system that recognizes whose life is at stake and upon whom the true burden of illness falls. We as consumers, as patients and families, should accept no less. Patient-centered care could deliver greater safety and success for patients and honest pride for clinicians -- not bad outcomes, I would say.
Dr. Sederer's book for families who have a member with a mental illness, The Family Guide to Mental Health Care, will be published by WW Norton in the spring of 2013.
The opinions expressed here are solely mine as a psychiatrist and public health advocate. I receive no support from any pharmaceutical or device company.
Visit Dr. Sederer's website (www.askdrlloyd.com) for questions you want answered, commentaries, movie and book reviews, and stories.
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