Improving the Quality of Care – Medical Errors
By Thomas Biancaniello M.D.
A lot has been written since the Institute of Medicine report of 1999 “To Err is Human” was published suggesting that between 44,000 to 98,000 deaths per year occurred do to medical errors. While some progress has been made in addressing the problem of medical errors, we are not nearly where we need to be to improve the quality of our health care. When compared to airline safety for example, the risk of death is less than 1 in 10 million while in health care the risk is suggested to be greater than 1 in 500. Defenders of the medical community like to respond that medicine is different; it is not an exact science such as engineering. This however misses the point. To reduce errors in any system you need to address culture and processes. This is illustrated in medicine by the improved safety rate and reduced errors in anesthesia. Over the last 25 years the risk of death from anesthesia has dropped from 2 per 10,000 administrations to 1 to 200,000 to 300,000. While it is certainly true that this improvement is in part do to safer anesthetic agents and improved technology of administration and monitoring, it is also because of the development of procedures and protocols to reduce variation and a culture of promoting safety by the practitioners.
The barriers to error reduction are many, among them are: hierarchical cultures, blame oriented society, overworked staff, and practitioner variation in treatments for the same conditions. Many health care systems and hospitals are trying to create a culture of safety. They enlist help from organizations like the Institute for Healthcare Improvement to take advantage of expertise and consultants in quality and safety.
Changing the hierarchical culture is difficult in a system where the physician is the captain. It is difficult to question orders that come from above, and thus those charged with carrying out the orders feel uncomfortable questioning even when they suspect it is incorrect. After an incident occurs, the staff often admits they thought it was wrong but went ahead. This is analogous to the airline industry, where analysis of the flight data recorders clearly demonstrated that a co-pilots knew they were heading into danger and if the captain was questioned at all, it was tenuously done. There was a disincentive to questioning the captain since making captain was dependent on favorable reviews by captain.
Airlines adopted “cockpit management” courses required for flight crews that emphasized speaking up when questions of safety arouse. Unfortunately, in the medical community the blame culture is strong and it is easier to blame, punish or fire someone than to look for the real causes.
Error rates and mistakes increase when staff is overworked, work long hours and are forced to take on additional tasks and functions due to under staffing. Even though state laws and residency rules for physicians-in training restrict work hours, those rules do not apply to attending physicians.
Medicine is unfortunately not a precise science and many conditions and diseases do not have evidence based processes and standard treatments so there is a lot of practitioner variation. When there is variation in care, there are more opportunities for error than if there were established protocols and guidelines that are well known and practiced by health care givers. There would be a higher likelihood that errors would be easily recognized before reaching bedside.
The real causes usually turn out to be process errors and usually are not the result of one single error or mistake, but a series leading up to the error. This is often described as the “swiss cheese effect”. Normally, if for example a pharmacist fills the order wrong, the nurse discovers it and the patient is never impacted. But if the nurse is in the middle of preparing it for administration and someone (most often a physician) demands attention, which will distract the nurse, who will resume the preparation without noticing what might have been recognized. So the checks and balance is overridden, the holes on the cheese line up, and the error occurs. Some hospitals have put red carpets in the medication preparation area where it is forbidden to interrupt a nurse when standing on the carpet preparing the medication.
In the past the result was usually led to someone getting fired or counseled. Now, in the better institutions a root cause analysis is done to look for the real causes and the processes to be improved. Many institutions are trying to establish a “just culture” where no blame is assigned for most mistakes and at the same time holds those accountable for rule violations and incompetence.
A barrier to engaging practitioners in this analysis of cause is the litigious atmosphere particularly in New York. If a practitioner is involved in a adverse event, they are often counseled by their attorneys not to say or write anything because it will be discoverable in a lawsuit. Valuable information from those involved is lost. This is not the case in other states and federal jurisdiction where quality improvement participation is protected.
Malpractice attorneys frequently claim that medical legal system will improve care. In fact it does not and it turns out often doesn’t address most cases of negligence. A landmarkstudy published in the New England Journal of Medicine in 1991 analyzing New York data. Of the 280 patients who had justified reasons for filing claims by the study reviewers, only 8 filed claims. They concluded from the study that the system rarely compensates injured patients and rarely identifies those responsible for substandard care.
It is not really a surprise that the threat of lawsuit does not improve the way people take care of patients. Most don’t get up in the morning wanting to make mistakes or be incompetent at what they do, especially health care workers who daily witness bad things happening to their patients from their afflictions.
The victims of medical errors are not only the patients and their families, but also caregivers and society as a whole. The effects on a practitioner who makes an error can be very devastating. There is increased absenteeism, leaving the institution and profession, increased of mental health issues and suicide. Few health care facilities provide enough support or resources to help clinical caregivers recover from effects of being involved in a medical error or adverse event.
Finally, there are the financial implications of medical errors. Poor care is expensive and the costs are borne by all of us regardless of who the payer is, the cost will be passed on to the taxpayer in the case of government programs or premium payers for insurance carriers. The NIH estimates that the cost of medical errors is over $17 billion per year. The government has begun to address making institutions responsible for the expenses generated by errors. Medicare started with a list of ten “reasonably preventable” conditions and Medicaid in our state of New York has now adopted the concept with “Never Events”. New York Medicaid now has a list of fourteen conditions that are not re-imburseable:
- Surgery performed on the wrong body part
- Surgery performed on the wrong patient
- Wrong surgical procedure on a patient
- Foreign object inadvertently left in patient after surgery
- Medication error
- Air embolism
- Blood incompatibility
- Patient disability from electric shock
- Patient disability from use of contaminated drugs
- Patient disability from wrong function of a device
- Incidents whereby a line designated for oxygen intended for patient is wrong item or contaminated
- Patient disability from burns
- Patient disability from use of restraints or bedrails
- Patient disability from failure to identify and treat hyperbilirubinemia (bilirubin in blood) in newborns.
Institutions have established procedures to make these and other errors less likely. “Time outs” are now common in which the participants stop before the procedure and go through a verbal review of what the procedures is, positive identification of the patient, the procedure, the side and site involved, check that images of the patient are available, whether the appropriate equipment and medical devices are at hand. Others have instituted checklists similar to what pilots do before taking-off for specific procedures and protocols rather than relying on memory. Institutions have also official adopted guidelines and protocols of care that are endorsed by various groups such as the American College of Cardiology, American College of Surgery and others to be sure that patients receive the best scientific or expert consensus care currently available. This generally assures that the best available evidence rather than the anecdotal experience of individual practitioners determines patient outcomes.
Thomas Biancaniello, MD is a Professor of Pediatrics (Cardiology) Columbia University Medical Center, Former Chief Medical Officer, Stony Brook University Hospital, Emeritus Professor of Pediatrics and Medicine, Stony Brook University