Preventable Medical Errors-A National Disgrace - The Future of Medicine
We all assume that our health care provider will not make mistakes, at least not when treating us. But doctors, nurses, physical therapists, pharmacists, and the rest are all human and endowed with a common characteristic, namely, they all make mistakes just like the rest of humanity. Certainly, no one comes to work in the morning determined to make a mistake; indeed, a lot of effort and energy goes in to not making a mistake-but it still happens. In this chapter, we will review why errors occur and what is being done to prevent them in the future.
The Institute of Medicine (IOM), in a landmark publication in 1999, wrote that as many as forty-four thousand to ninety-eight thousand Americans die as the result of preventable errors in American hospitals each year. These are incredible numbers, and many have disputed them. But even if only half or 10 percent occur, that is way too many. Some studies, however, would suggest that the IOM estimates are too low. The IOM report was entitled "To Err Is Human," an apropos title since that is the basic problem. Humans make mistakes. Humans will continue to make mistakes. Well-educated and well-trained humans will make mistakes. Humans that double-check will still make mistakes.
It's been seven years since the publication of the IOM report, and much has been said and written. Indeed, many hospitals have started to reduce error rates. But errors still abound, and not nearly enough has been done to make a real and lasting dent, much less to truly drive them down toward zero. Beginning with boards of trustees, little attention is focused on safety; rather it is focused on the financial status of the hospital. Most improvements to date have been the result of mandates, principally from the Joint Commission on Accreditation of Healthcare Organizations (JACHO). It is time for America's hospital leaders and especially trustees to insist that appropriate changes be made. In this chapter, I will review what needs to be done and suggest specific actions.
Hospital Culture and How It Needs to Change
Averge American Hospital
Serious Adverse Events Per Year
Unfortunately, the usual hospital culture is one of chastisement and punishment of the culprit: if we make it clear that we will not tolerate such mistakes, certainly people will be more careful. Nothing could be further from the truth, and such a culture encourages covering up and not reporting errors. No one wants to be labeled as inferior; no one wants a letter of reprimand in his or her personnel file or medical staff office. A professional needs to maintain their license to practice. Will an error jeopardize that?
The cure is not to punish those who make mistakes-since we all do-but to create systems to detect errors, correct errors, and help to prevent errors. At the same time, we need to foster a culture of openness where errors and near misses are discussed and communication is improved. All of this will require that trustees take the lead and insist that safety is critical and that hospital executives will be evaluated on their performance with safety, not just for financial success.
Modern hospitals are the cathedrals of the modern era. They anchor dynamic civic and financial activity and are extraordinarily complex. Patients are complex as are treatment protocols. The coordination needed between different types of health care providers and their dependence on technology adds to the complexity. Throw in the large volume of information needed for decision making and the residual uncertainty inherent in making medical decisions, and the modern hospital becomes still more complex.
Many patients receive more than ten medications per day, many of which are inherently dangerous. The operating room is the financial engine of most health care facilities and also the source of many of the most published adverse events. Nosocomial infections are all too often the result of physician and staff error in performing well-established procedures. In order to improve safety, the hospital must first create a culture of safety, and then design patient safety initiatives that take into account technology upgrades and human factors.
The culture of safety must include an institutional commitment from the board and CEO to adopt appropriate systems and provide required resources of people, time, and dollars. The culture of safety requires a nonpunitive attitude toward medical errors and open communication about errors so that near-miss data can be collected and analyzed to find the root cause of the errors. Accountability must start with the CEO and spread on down through the ranks of physicians and staff to reinforce the desired behaviors.
Human factors that can improve safety include effectively enhancing leadership and management of each hospital unit, improving communication and information transfer, and enhancing training. Using an effective system, such as crew resource management to improve teamwork and align performance measures, reward, and recognition systems, will reinforce the desired changes in both the process and the individuals' behavior.
Process changes, constant checking to improve them, and rigorous adherence to following them, are critical to improving safety. Patient identification, medication administration, infection control, operative standards, and information/communication all need to be considered a process, require agreement, and require subsequent adherence.
Highly reliable organizations become that way because of constant vigilance and continued improvement of processes by testing, auditing, drilling, creating redundancies, and building accountability into everyone's role-regardless of individual preferences.
Once the culture and the human factors have been addressed, multiple technologies can dramatically enhance safety. But it is essential that the culture and human factors are addressed first. Technologies without the needed underlying culture will not be of much help. Whether you chose the lower (44,000) or higher (98,000 preventable deaths) numbers in the IOM report as more realistic of the typical hospital, that is still too many lapses in patient safety in U.S. hospitals.
So while addressing the culture issues and developing a nonpunitive environment, the areas to address first with systems changes are medication errors (including blood product administration), operating room and related perioperative events, and hospital acquired infections. In the process, it makes good sense to assure that:
- hospitals and their surgical and medical staff only do procedures that they do in large numbers (experience counts)
- intensive care units are staffed by those trained in intensive care medicine (intensivists not generalists)
- resident physician-trainees are closely supervised (trainees are just that)
Last Modified: June 11, 2010