To Err is Medicine? Anatomy of a Modern Problem
When I was a resident in internal medicine many years ago, I saw an elderly woman who came to the ER complaining of chest pain and shortness of breath. She had a history of heart disease. When I listened to her chest, the crackles I heard emanating from her wet lungs told me she had congestive heart failure. I treated her chest pain and gave her diuretics to help her get rid of the water that was making her drown in her own bodily fluids. After an hour or two of treatment, she felt better. I decided to send her home. But as I did, a little voice in the back of my head told me that was a bad idea.
A few hours later, it was time for me to go home. Call it a premontion or a sick feeling, but on my way out the door, I passed through the ER. "Do you remember that patient you sent home," a nurse asked me.
'Do you remember' are the three worst words a physician ever hears. That's because the triplet is usually followed by an update that the patient is doing poorly. And so she was. The patient I had sent home had returned near death. Despite heroic efforts, she could not be saved.
I remember her name like it happened yesterday. A wise colleague once told me "you never forget the names of those who die."
Ever since that day, I've been a student of medical malpractice.
In 1999, the US-based Institute of Medicine (IOM) published a seminal report entitled 'To Err is Human'. In it, the IOM said between 44,000 and 98,000 Americans die each year of preventable medical errors. According to the Canadian Adverse Events Study, as many as nearly 24,000 Canadians die in hospital of preventable medical errors.
If you do the math, as many people die in Canada every few days from preventable medical errors as die in commercial plane crashes. When a plane drops from the sky, it makes headlines. Not so, when it's one patient who dies.
What are the major sources of medical errors?
* Complexity of modern health care. These days, patients live longer. By the time I see them, it means they are older and often have four or five major illnesses. That increases the potential that treating one condition makes the others worse. More and more patients are on experimental treatments that are frankly beyond the ken of your average frontline doctor or nurse
* Speed kills. Twenty years ago, we saw 70-80 patients a day in my ER. Today, it's more like 130-140. The faster I work, the less time I have to entertain that still, small voice in my head that tells me whether to send my patient home or admit her.
* Pardon my interruption. All of us know what it's like to be interrupted while working on a task at work. Medicine is no exception. If anything, it's worse because each interruption tends to be entertained because it's assumed that if the interruption is about a patient, then it must be important. But health care professionals aren't any better than the rest of us at handling them. In the ER, if I'm interrupted once while asking you about why you've come to hospital, I can usually get back on track. Two interruptions, and it gets dodgier. Three interruptions, and I probably won't take a proper history from that point onward.
* Forgeting the simple stuff. Many preventable errors in hospital have to do with infection control. Health care professionals continue to fail to wash hands before and after every patient contact.
* Medication errors. A disproportionate number of preventable medical errors involve medications. These include the wrong drug, the wrong dosage, and even drugs given to patients with known allergies. Some of these are the result of human error; others have to do with a system that until recently was not designed to detect and root them out. In some cases, the wrong drug is given because the name sounds too much like another drug. In other cases, two dissimilar drugs (one benign and the other dangerous) are contained in nearly identical vials.
* Forgive me, I'm human. We tend to forget that health care is an art, not a science. We expect that there's a right answer for every set of clinical circumstances. Often, we're making a best guess based on incomplete information. We also tend to forget that health care is practiced by human beings, not robots or computers. When arriving at a diagnosis or course of treatment, we may forget to ask a pertinent question or fail to take a pertinent detail into account. Unfortunately, we have a long-rooted culture in health care of feeling unhealthy shame about medical mistakes. In my opinion, that unhealthy shame makes it difficult for people like me to talk about our mistakes and difficult for people like me to listen to the mistakes of others.
We at WCBA think looking at medical errors and creating a culture of patient safety in health care should jump to the top of the priority list. That's why we're hoping you'll attend our townhall on Tuesday October 12 at Glenn Gould Studio. If you can't attend, please post a question on our blog or email it to email@example.com so that we can pose it to our panel of experts.
More on that tomorrow.