Consider this alarming scenario: A doctor prescribes the wrong dosage of a drug for a patient. The nurse working the case does not spot the doctor’s error. The pharmacist also fails to notice the problem, and fills the prescription as written.
Who’s at fault for putting the patient in danger?
More than any individual, flaws in the system are most likely to blame for costly, sometimes tragic medical mistakes, according to professors at the Georgia Regents University-University of Georgia Medical Partnership.
“Any time an error occurs, it occurs because not just one person made an error, but because there probably were a series of errors,” says Don Scott, director of essentials of clinical medicine at the partnership.
Scott teaches first- and second-year students the skills essential for being doctors, or as he describes it, “everything but the basic science.”
“To Err is Human,” a 1999 report from the Institute of Medicine, estimated that medical errors kill as many as 100,000 people a year. A follow-up report in 2009 found no noticeable improvement in patient safety.
But now it appears that the 100,000 number may be low.
A study in the current issue of the Journal of Patient Safety looks at people who receive some type of preventable harm when they go to a hospital to receive care. The new study estimates that each year, 210,000 to 440,000 such people are harmed sufficiently that it contributes to their deaths.
Given these statistics, it’s understandable that reducing fatal blunders is a prime goal of medical educators.
At the Athens partnership, professors teach students to think critically and act deliberately. They do this with a mix of mental calisthenics, including exercises in “root cause analysis,” and the use of checklists in operating rooms and other clinical settings.
Root cause analysis exercises require students to consider all the possible factors that could be contributing to an individual patient’s illness; checklists remind doctors to take every step required for high-quality care.
Like students working their way through a root cause analysis, Scott said, doctors and other health providers must consider all the options and identify the root causes of medical mistakes.
A less punitive, more positive approach
The fight against medical errors, in Scott’s view, is not so different from using a carrot and a stick to motivate a mule pulling a cart. The mule goes faster for two reasons at once: getting the carrot and avoiding the stick. In medicine, rewards for safe, high-quality care would be the carrot and punishments for mistakes would be the stick.
But until recently, Scott believes, health policy has focused too much on the stick and not enough on the carrot. Health care providers are punished for making mistakes but are not given enough incentives to provide quality care.
The Affordable Care Act will make “carrots” more common. The Medicare Shared Savings Program provides new financial rewards to health care providers who meet benchmarks for quality care.
But preventing errors involves more than rewards and punishments. Sometimes the issue is as simple as the routine for using medical devices.
A machine as basic as the one used to deliver drugs through an IV can be a source for errors, says Dr. Stephen Lucas, a professor of quality and safety at the partnership and clerkship director for Athens Pulmonary Associates.
When he investigated a case involving a hospitalized patient given a dangerously high dose of medication, he tracked the root cause not to an individual practitioner, but to a misunderstood feature of a bedside pump.
Proper drug dosage depends on a patient’s weight, and the pump allowed doctors to enter that weight in either pounds or kilograms. A kilogram is more than twice the weight of a pound. On one occasion, a doctor thought he was entering the patient’s weight in pounds when in fact the machine was set for an entry in kilograms. As a result, the patient received a significant overdose of the drug.
Rather than going after the person who made the mistake, Lucas says, it was more important to stop offering doctors the choice between pounds and kilograms. Instructing physicians to enter weights exclusively in pounds can cut down on errors, he says.
If it’s on the list, do it!
Checklists are another of Lucas’ favorite strategies for making hospital care safer. Being required to use a checklist reminds doctors to make sure they do simple things, such as washing their hands before every patient encounter, wheeling the right patient into the operating room, and operating on the right organ.
Long considered essential in such fields as aviation, checklists have been used off and on in medicine for decades. They’ve been in the spotlight since 2010, when Dr. Atul Gawande, a Boston surgeon and best-selling author, wrote about them in the New Yorker and later in a book focusing on their effectiveness in the operating room.
There is ample evidence that they work. When the World Health Organization studied hospitals in eight cities across the globe, researchers found that using surgical checklists lowered the incidence of surgery-related deaths and complications by one-third.
Putting checklists into every hospital, however, has proved difficult despite their benefits. And Lucas says that once checklists are in place, their effectiveness hinges on teamwork.
“I think the real leap forward is going to be when every doctor and every nurse and every person who has anything to do with the patient takes very committed and total responsibility for making sure that patient’s safe,” says Lucas.
“If your surgeon’s going to sit over in the corner and say, ‘You guys do your checklist, and let me know when I can start,’ that’s not good.”