INTERNAL BLEEDING: OUR EPIDEMIC OF MEDICAL MISTAKES
From the 19th
Annual Primary Care Medicine: Principles and Practices,
held October 13-15, 2004, in San Francisco, and sponsored by the University of
California, San Francisco, School of Medicine.
Robert M. Wachter, MD, Professor and
Associate Chairman, Department of Medicine, University of California, San
Francisco, and Chief of Medical Services, University of California, San
Francisco Medical Center
| Institute of Medicine (IOM) report: 2004 was fifth
anniversary of IOM report, "To Err is Human"; launched widespread scrutiny
of hospital patient safety issues and at least nominal commitment to
improving patient safety; authors used 10- to 15-yr-old data to estimate
that medical errors kill 44,000 to 98,000 patients annually; assuming
United States has ≈6000 acute-care hospitals, IOM
estimates imply 7 to 10 fatal medical errors occur per year at each one,
not including similar deaths at skilled nursing, long- term care, or
outpatient facilities; according to report, figures equivalent to jumbo
jet crashing every day |
| Possible reasons for neglect of patient safety:
abstract nature of data ("one death is a tragedy, a million deaths is a
statistic"—Joseph Stalin); growing complexity of medical procedures and
technologies, leading to less emphasis on common sense; systems must be
developed to ensure safety |
| Case discussion: nurse "Jane Hyatt" approaches day's
first patient and discovers he is not breathing; she calls "code blue";
code team arrives; one doctor inserts catheter for intravenous (IV) line;
syringes of atropine, epinephrine, and bicarbonate passed over patient's
chest "like cheese puffs at spirited dinner party;" team of doctors and
nurses, most of whom never worked together before, shout instructions and
yell questions; "semi-organized bedlam"; patient is man in his late 70s;
respiratory therapist administers O2 while
doctor compresses patient's chest; another doctor yells "Stop!" after
finding faint pulse in patient's groin; other code work continues as
intensive care unit contacted to reserve bed; team leader asks several
times why patient went into cardiac arrest; senior resident "Aaron Regal"
finds patient's chart, returns to room, and declares that chart states "do
not resuscitate" (DNR; some hospitals attach large red stop sign to front
cover of chart; here, blood-red form slipped into chart itself); team
dismantles IV line, packs up syringes, tubes, and medicines, and files
quietly from room; another resident threatens to file incident report
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Obstacles to designing better system: lack of
standardization among hospitals; each has own way of identifying DNR
patients (eg, colored wrist bands); confusing when institutions
already use them in multiple colors to convey different information, and
when DNR red at one hospital but blue at another; signs near patient's bed
may get lost; papers in patient's chart may be lost or overlooked; without
standardization, problems compounded, not solved |
| Outcome of case: "Nurse Hyatt", 22 yr of age and
recent nursing school graduate, returns to patient's room; wonders why no
one told her at shift change that patient was DNR, but assumed doctor may
have annotated chart and forgot to inform staff; by now, patient's heart
has stopped; as room cleanup proceeds, she notices chart lying at foot of
bed and flips through it; realizes "Dr. Regal" pulled wrong chart and that
patient should have been resuscitated; code team summoned back to
patient's bedside, but too late |
| "Swiss cheese model" of medical errors: developed by
psychologist James Reason while studying accidents in complex
organizations (eg, airplane crashes, train derailments, and
tugboat accidents); concluded that human error common, but high-risk
industries prevent catastrophic consequences by building in several layers
of protection; each layer may develop holes, like slices of Swiss cheese;
disaster strikes when holes line up and sentinel event (error) falls
through; model powerful because it focuses on safety systems ("cheese"),
rather than error in isolation; after-the-fact analysis of catastrophes
often reveals that ≥1 safety layers failed at least
once before disaster occurred (suggests that system vulnerable); however,
some precautions that work in other industries not practical for medicine
(eg, safety checklists; untenable in urgent medical situations in
which excessive delay could be fatal) |
| Case analysis: factors to examine include any safety
system already in place; composition of code team (in this case, many of
them had never worked together before); training of code team (if any;
often does not accurately simulate true code situation)
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Culture of low expectations: assumption by
house staff that if patient's status changes, they will not necessarily be
informed; improvement requires not just better communication, but ensuring
that even most junior staff members feel comfortable questioning orders
that do not seem right, even if it means delaying case by chief of
cardiothoracic surgery (and even if everything in order)
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| Creating safer systems: build in redundancy
(eg, have nurse read orders back to doctor who places them);
redesign equipment to have "forcing functions" (features designed to
anticipate and prevent human errors, eg, cars that require
drivers to step on brake before going into reverse); establish enlightened
culture of safety (as in aviation, where subordinates can challenge most
senior pilots when necessary; in 1977, after worst airplane collision in
history and first involving 747, found that copilot and flight engineer
did not contradict respected senior pilot's erroneous assertion that
runway clear) |
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Secret of effective safety programs:
connecting "top-down" management (senior doctors and executives walking
floors, attending rounds, analyzing incident reports, and communicating
with patient safety officers) with "bottom-up" staff (nurses, doctors,
dietitians, clerks, and other hospital staff trained in culture of
safety); hospitalists may be best coordinators of such efforts
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Information technology: computerized physician
(or provider) order-entry (CPOE) systems may provide evidence-based data
(prevent error and support human decision makers); current systems still
have glitches; users estimate they reduce errors by one third; cannot
overcome problems inherent to faulty culture or hierarchy
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Workforce issues: staffing and training models
should address hierarchy problems; workforce issues may directly affect
safety (one study linked higher nurse-to-patient ratios with better
patient outcomes) |
| Obstacles to creating safer systems: cost
(unrealistic to expect short-term compensation in form of greater
efficiency, lower malpractice premiums, or other cost savings); federal
government has allotted $27 billion for "progress" (National Institutes of
Health), compared to $60 million for safety (Agency for Healthcare
Research and Quality [AHRQ]); culture (doctors often still trained to be
"macho", risk-taking "Chuck Yaeger types," rather than duller but more
safety-minded "John Glenn types" for culture of safety to prevail);
complacency ("the day you think your hospital is now safe is the day it is
becoming dangerous again"; constant vigilance essential)
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| Conclusions: errors cannot be ascribed to laziness or
lack of intelligence; bad doctors and nurses exist, but real task is to
create safer systems; aggressive approach can have big impact
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Organizations working together on safety
measures like universal wrist bands: none; Joint Commission on
Accreditation of Healthcare Organizations (JCAHO) responsible for most
standardized safety systems now in place (eg, reading back
instructions; eliminating confusing abbreviations for medication)
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Blameless examination of errors: focus on
systems laudable, but does not mean no bad doctors or nurses; people
should be held responsible when they fail to follow safety rules;
mechanism for identifying these individuals needed; hospitals might
consider establishing "code orange" for handling unreasonable staff
members; operating room standardization may also help (instead of
customizing setup for each surgeon) |
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Patient safety resources: speaker and
colleagues at University of California, San Francisco edit Morbidity and
Mortality Rounds on Web (www.webmm.ahrq.gov); interesting real-life cases
of medical errors with expert commentary; free, and continuing medical
education credits available; Patient Safety Network (www.psnet.ahrq.gov)
features new tools, surveys, resources, meetings, and other information
related to safety; updated weekly; "world's most robust library on patient
safety" |
Educational Objectives
| The goal of this program is to review for physicians the requirements
for a culture of safety in hospitals. After hearing and assimilating this
program, the clinician will be better able to: |
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1. Discuss the key points of the Institute of
Medicine report "To Err is Human." |
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2. Describe the "Swiss cheese model" of
errors. |
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3. Identify the components necessary to ensure
patient safety. |
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4. List some of the obstacles to changing
hospital cultures and procedures. |
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5. Define the term "forcing function" as it
applies to medical technology. |
Discussed on This Program
Atropine sulfate [Atropine Sulfate Ophthalmic, Atropine Care,
Atropine-1, Atropisol, Isopto Atropine, Sal-Tropine, AtroPen]
Edrophonium chloride/atropine sulfate [Enlon-Plus])
Epinephrine [Adrenalin Chloride, Adrenalin Chloride Solution, Epifrin,
EpiPen, EpiPen Jr., Glaucon, microNefrin, Nephron, Primatene Mist, S2]
Suggested Reading
Cook
RI: Safety technology: solutions or experiments? Nurs Econ
20:80, 2002; Grasso BC et al: What is the measure of a safe
hospital? Medication errors missed by risk management, clinical staff, and
surveyors. J Psychiatr Pract 11:268, 2005; Landrigan
CP: The safety of inpatient pediatrics: preventing medical errors and
injuries among hospitalized children. Pediatr Clin North Am 52:979,
2005; Linda T. Kohn, et al, eds: To Err is Human. Washington,
DC: National Academy Press, 1999; MacReady N: Second stories,
sharp ends: dissecting medical errors. Lancet 355:994, 2000;
Mycek S: A clean sweep. Patient safety beyond error prevention.
Mater Manag Health Care 14:38, 2005; Ramsey G: Nurses,
medical errors, and the culture of blame. Hastings Center Report 35:20,
2005; Reason JT: Managing the Risks of Organizational
Accidents. Aldershot, Hampshire, UK: Ashgate Publishing, Ltd, 1998;
Singh R et al: Computer visualisation of patient safety in
primary care: a systems approach adapted from management science and
engineering. Inform Primary Care 13:135, 2005; Smaling J, Holt
MA: Integration and automation transform medication administration
safety. Successful eMARS mandate a multifold integration strategy that includes
people, processes, applications and technology. Health Man Technology
26:16, 2005; Stetina P et al: Managing medical errors—a
qualitative study. Medsurg Nurs 14:174, 2005; Wachter R,
Shojania K: Internal Bleeding: The Truth Behind America's Terrifying
Epidemic of Medical Mistakes. New York: Rugged Land Publishers, 2004;
Wachter RM, Shojania KG: The faces of errors: a case-based
approach to educating providers, policymakers, and the public about patient
safety. Joint Comm J Qual Saf 30:665, 2004
Faculty Disclosure
In adherence
to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to
disclose any significant financial relationship with the manufacturer or
provider of any commercial product or service discussed. For this issue, the
faculty reported nothing to disclose.
Dr. Wachter was recorded at 19th Annual Primary Care Medicine:
Principles and Practices, held October 13- 15, 2004, in San
Francisco and sponsored by the University of California, San Francisco, School
of Medicine. The Audio-Digest Foundation thanks Dr. Wachter and the sponsor for
their cooperation in the production of this program.
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