Avoiding Mistakes -- Targeting Hospital Systems

Did you know that a person is more likely to be injured or die because of a medical error than as a result of driving or flying? Studies show that between 44,000 and 100,000 people die in U.S. hospitals every year due to medical errors.

These errors can be attributed to human factors such as lack of experience, skill, or motivation, which become greater when you add fatigue, stress, and interruptions. However, there are other reasons for errors beyond the fact that humans are not perfect. In a new book, Internal Bleeding: The Truth Behind America’s Terrifying Epidemic of Medical Mistakes, Drs. Robert M. Wachter and Kaveh Shojania of the UCSF Medical Center claim that system failures, not bad doctors are the root cause of the problem. Here is part of an interview with Dr. Wachter, conducted by Sabin Russell.

Q: If medical errors are such a big problem, shouldn’t we be getting rid of the people who are making them?

A: We have not done a very good job of weeding out [people who are incompetent] . . . But most errors are being made by good, caring people, most of whom are well-trained to do their best.

Take the Duke case. (One year ago, 17-year-old Jesica Santillan died after a heart-lung transplant at Duke University Hospital because the organ donor had a different blood type, which was missed in the early preparations for surgery). This was a spectacular, highly committed, wonderful surgeon. You are not going to prevent that type of error by kicking him out of medicine.

Q: So the solution is to fix the system, rather than to punish the people who make the mistakes?

A: It’s closer to the truth than the paradigm that errors represent individual screw-ups by people who are either not smart enough or not working hard enough. We have to recognize that human beings will make mistakes. It requires a new systems approach.

Q: You and many other medical quality experts refer to the airline industry as an example the health care field should follow in terms of improving safety. Why?

A: The lesson from aviation is that they said, “We’re not going to fix this by getting the pilots to be more careful.” They focused on the error-prone things we all do . . . Accidents are almost never caused by one thing. It’s like the stars all aligning in a nasty way.

Q: So what are some examples of things that medicine might pick up from aviation?

A: Teamwork. The use of checklists and readbacks. Routine precautions, such as signing the site for surgery (to avoid disastrous examples of operating on the wrong limb). Getting rid of high-risk abbreviations that can be misread, and eliminating the use of decimal points in prescriptions. . . so 1.0 milligram is not mistaken for 10 milligrams . . .It’s simple stuff that we should have been doing 20 years ago.

Q: Aren’t there a lot of differences between medicine and aviation?

A: Yes. With airlines, you have a machine. You load it up, fly it and land it. That’s trivial when compared to a hospital. We have 500 passengers, each of them comes in and leaves at a different time. Each is going to a different destination. Each is ordering from a different in-flight menu. Illness creates an urgency that does not exist, at all times, in aviation.

Q: Are computers the answer to medical quality?

A: If you computerize bad practices, you have just hard-wired the bad practices. . . But take the problem of handwritten prescriptions. It’s an insane system that needs to be replaced by something called computers. And we have not done it yet.

Q: You do not seem to believe that the malpractice system is what is needed to keep doctors on their toes. But doesn’t it raise the emphasis on safety?

A: If I slip, because I am a human being, you are not going to fix the error by taking me out back and shooting me or by suing me. We spend so much time and effort finding fault, but the medical malpractice system is incredibly inefficient. Sixty cents of every dollar goes to some other place than the patient.

Situation

Techniques that reduce errors

1. Something doesn’t “seem right.” You feel uneasy or helpless, but believe that speaking out won’t make a difference.

Learn to identify and act upon warning signs.

2. You notice a change from standard procedure or a lack of consistency in how a procedure is performed.

Follow procedures carefully. Don’t take shortcuts.

3. You believe that a complex procedure is being performed improperly.

Decide if the procedure can be simplified.

4. You encounter unexpected findings.

Be aware that instruments can be incorrectly calibrated.

5. A procedure has not changed although it has been associated with previous errors or near misses.

Find out the root cause(s) of the past errors and revise the procedure.

6. You realize you are (or a colleague is) focusing too much attention on one aspect of a procedure.

Work to balance your attention on all parts.

7. A team member is “stuck on autopilot” and acting out of habit.

Be aware that people tend to become less vigilant over time.

8. You have to rely on your memory to recall exact details when you are doing more than one thing at the same time or ending your shift and need to communicate what you know to others.

Use automated or computerized technologies when possible. In verbal communication, use the “rule of 3” for information you receive—write it down, read it to yourself, and then read it back to the sender.

9. You have worked too many hours or are fatigued.

Don’t disregard human limitations. When these are ignored, errors are more likely.

get rid of
is stuck on autopilot
keep on their toes
kick out

load up
pick up
raise a red flag
rely on

screw up
speak out
take shortcuts
weed out