Learning and Adapting from Medical Errors 

Posted by Todd Borghesani

George Halvorson, the CEO of Kaiser Permanente says it best—the United States health-care system is “uncoordinated, unfocused, inconsistent, unmeasured, extremely inefficient, perversely incented, excessively expensive, and sometimes dangerous.” We don’t have a healthcare system, we have a sickness industry. The word system means a set of connected things or parts forming a complex whole. We have a siloed series of small businesses that compose a $2.5 trillion a year market run on handwritten notes.

As a result, 100,000 people die each year in the United States simply due to medical errors—the equivalent of 275-passenger jumbo jet  crashing every day. Not only is it alarmingly unsafe, it’s bankrupting us. It’s the antithesis of intelligent design.

We, as citizens of this great nation, didn’t choose this for ourselves. No forward thinking professionals designed it like they designed our interstate highway system. The sickness industry just happened. It sprang up over the course of the last 100 years in segregated pockets based on delivery processes that have existed since the days of Hippocrates.

Healthcare needs to move away from the “name, blame, and shame” approach. But this change has not been well-accepted in current-day medical community culture where tort and contract law act as a significant barrier to blame-free reporting (Liang, 1999). Despite limited examples of success, the core culture of the healthcare delivery system needs to change if preventable medical errors are to be identified, analyzed, understood, and eliminated. When a training strategy is based on a systematic, multidisciplinary approach which leverages real-life scenarios, communication protocols and informatics success can be realized.

Patient safety problems in health care are daunting. However, other industries have successfully faced similar safety challenges through a systematic, multi-disciplinary approach based on a fundamental knowledge of the nature of the safety problem and the application of systems-based solutions. For example, NASA, as well as the aviation, petrochemical, steel processing, nuclear power, and radiopharmaceutical industries, have created safety reporting systems that include actual events and close calls which are transformed into useful and effective information for learning (Barach and Small, 2000).

Understanding the epidemiology (i.e., the types and causes) of errors is essential in addressing error reduction. There have been three large hospital-based studies on the prevalence of medical injuries in hospitals. Two studies were conducted in the U.S. and one was conducted in Australia. Through these and other more limited studies, we have found that errors are more likely to occur in high risk situations e.g., in emergency care and operating rooms, in older patients with complicated care, and in patients with long hospital stays (Weingart et al, 2000, Bogner, 1994). We also know that inexperience is associated with medical error. Wu and colleagues found that house officers often err (Wu et al, 1991), and Lesar and colleagues found that postgraduate residents, when compared to other clinicians, make more prescribing errors (Lesar et al, 1990).

However, what limited knowledge we have about the prevalence, types, and causes of medical error is primarily reflective of care for adults in the acute setting and little is known about medical error in other settings. We also suffer from a lack of standardized and universal nomenclature and taxonomy for medical error making it difficult to identify, report on, analyze, and characterize the prevalence, types, and causes of errors and close calls. This type of information is critical for developing and implementing corrective actions.

The development and use of computerized protocols — the use of informatics — can help address this problem by describing explicit clinical care methods that help standardize clinical decision making (Morris et al, 1996). Healthcare practitioners are increasingly placed in situations wherein errors are bound to occur. This is the result of an increasingly complex health care system with complicated treatment options that continue to take place in systems with little standardization and few safeguards when compared to other industries (Bates, 2000). In this complicated environment, researchers have found that inexperience and poor training can lead to inaccurate diagnosing and treatment and a higher rate of human error (Leape, 1994, Bruining, et al, 1987).

In high-risk environments, mistakes are a fact of life. We will never “not make” them. What we can do, though, through a refactoring of how we approach teamwork, use communication protocols and informatics, is reduce their impact. Those of us who have worked under the combined pressures of time, environment and extreme situation understand that the key differentiator is training.

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