April 7, 2012


The Errors of Their Ways: Some 24,000 Canadians will die this year from medical mistakes. Even the most temperate doctors call this an epidemic. Why these mishaps persist despite, and even because of, medicine's growing sophistication (RACHEL GIESE, APRIL 2012, The Walrus)

THE AMERICAN medical industry has long known about the problem of adverse events, largely due to the rise in malpractice claims in the 1980s. When Hicks began his medical training, the received wisdom surrounding medical error was heavily influenced by malpractice litigation: someone had screwed up, and they would have to pay for it. Error was viewed as resulting from ignorance or negligence -- doctors or nurses gone rogue. Even the long-standing tradition of morbidity and mortality rounds (M&Ms, open discussions between physicians about their mistakes) contributes to this perspective. M&Ms often focus on content or skill -- on what a doctor didn't know, or didn't know how to do.

To determine whether litigation was improving or hindering care, the Harvard Medical Practice Study in 1991 quantified the scope and nature of medical mistakes. Its findings, chief among them significant rates of death and disability caused by medical mishaps, were startling. But the results didn't achieve traction outside the medical field until 2000, when the National Research Council published To Err Is Human: Building a Safer Health System, based on a report by the US Institute of Medicine. Among its most shocking statistics: "Preventable adverse events are a leading cause of death in the United States...at least 44,000 and perhaps as many as 98,000 Americans die in hospitals each year as a result of medical errors."

Shortly afterward, the British Medical Journal devoted an issue to the subject. "In the time it will take you to read this editorial, eight patients will be injured, and one will die, from preventable medical errors," the opening article announced. "When one considers that a typical airline handles customers' baggage at a far lower error rate than we handle the administration of drugs to patients, it is also an embarrassment."

It's so embarrassing, and the threat of litigation so unnerving, that physicians have long been reluctant to discuss mistakes. The BMJ editorial goes on to note that "we tend to view most errors as human errors and attribute them to laziness, inattention, or incompetence." Like Hicks, many doctors were taught that individual diligence alone should prevent medical errors, and that admitting their existence could lead to lawsuits, humiliation, or job loss. In Canada, Ross Baker -- now a professor of health policy at the University of Toronto and director of graduate studies at the university's Centre for Patient Safety -- followed these discussions with anticipation. He and his colleagues across the country involved in the then nascent health care safety movement hoped the alarming data would incite action here in Canada. Instead, To Err Is Human was viewed as proof that the American system was fundamentally flawed. So in 2004, Baker and Peter Norton, now a professor emeritus in family medicine at the University of Calgary, published a paper, The Canadian Adverse Events Study. "There was no conspiracy to hide this information," Baker says. "No one had looked carefully at the data before." The researchers erred on the conservative side in their estimate of preventable medical errors (by their count, up to 23,750 patients had died as a result of these mistakes in 2000), opting not to include incidents if they suspected any doubt or ambiguity about whether such occurrences constituted mistakes, which suggested that the problem is actually larger. (No formal follow-up has been done since.)

Paradoxically, the problem has been exacerbated as the field of medicine has grown more complex. In the 1960s, as scientific and technical wisdom developed, physicians began to specialize, which vastly improved medicine -- the more narrow the focus, the greater the expertise and skill -- but it meant that an individual patient's care was now shared among multiple practitioners. In the case of a child who suffers a head trauma, for example, her treatment may be handled by dozens of professionals: paramedics, emergency doctors and nurses, a neurologist, a neurosurgeon, an anesthesiologist, surgical and ICU nurses, pharmacists, pediatricians, residents and medical students, occupational therapists, and so on. As the patient is handed from one to the next, myriad opportunities arise for her medical history to be lost, for conflicting drugs and treatments to be prescribed, for lab results to be delayed, for symptoms to be overlooked, and for confusion in the transmission of vital information.

James Reason, a British psychologist specializing in human error, has dubbed this "the Swiss cheese model," in which small, individual weaknesses line up like holes in slices of cheese to create a full system failure. And in a modern hospital environment -- a busy, stressful setting with many competing priorities, where decisions are made under duress, with frequent shortages of nurses, beds, and operating rooms -- a patient's care slipping through the holes at some point is almost inevitable.

Failings in teamwork and communication compound these flaws, which according to patient safety research lie at the core of preventable adverse events. Baker likens the health care field to "a series of tribes who work together but don't really understand one another." To put it less diplomatically: egos, territorialism, and traditional hierarchies can create toxic environments in hospitals, where senior physicians disregard input from nurses and junior staff, who in turn become resentful and defensive.

The patient safety movement Baker helped initiate in the early 2000s profoundly changed the conversation about medical error. It was no longer a matter of assigning blame, but of improving bad systems. In Canada, the Halifax Series, an annual symposium about quality in health care, was launched in 2001; and a few years later, the Canadian Patient Safety Institute, an advocacy and research body, opened its offices in Edmonton and Ottawa. Hospitals across the country recruited safety experts to advise them, and to encourage physicians and other practitioners to talk more openly about adverse events.

The focus on flawed systems made addressing the problem an easier sell, especially as it became evident that the rampant problems in health care were errors of omission, not commission. While the old malpractice model routed out villains, the systems approach tackled the day-to-day snafus that frustrated everyone: long waits in the emergency department, under-stocked supply rooms, vague lines of communication, and so on.

To Kaveh Shojania, co-author of the 2004 book Internal Bleeding: The Truth Behind America's Terrifying Epidemic of Medical Mistakes, shocking statistics about medical error are useful mainly as headline grabbers, drawing attention to more quotidian concerns about quality improvement. Shojania, an internist at Sunnybrook Health Sciences Centre in Toronto and director of the Centre for Patient Safety at U of T, says the root of the problem is the ad hoc way medicine was established over its long history. He compares it to a series of cottage industries that developed with no larger organizing vision. The medical industry has grown so vast and complicated that tackling inefficient systems is akin to untying a Gordian knot.

In his cluttered office on the sprawling Sunnybrook campus, Shojania, an Eeyore-ish fellow in a rumpled suit, navigates through stacks of files, books, and papers to show me an image on his computer. It's a drawing of a Rube Goldberg pencil sharpener, a ridiculously convoluted device that involves a kite, an iron, an opossum, a rope, a woodpecker, and moths. That's the current medical system, he tells me by way of analogy. "This isn't an issue of incompetent people making stupid mistakes," he says. "It's many average, decent people working in poorly designed systems. Most medical mistakes were accidents waiting to happen."

Posted by at April 7, 2012 7:42 AM

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