Medical errors, gaps in quality of care more than a case of Whoops, we goofed’
Let’s change the system so it doesn’t happen again’
A few weeks ago, John Chessare, MD, MPH, chief medical officer of Boston Medical Center and associate dean for clinical affairs at Boston University School of Medicine, was leading a group of surgical students on grand rounds when he decided on an unusual tactic to make a point.
"I started by asking a group of questions," he recalls. "I asked, When was the last time you ordered a lab test and didn’t get it back? Lots of snickers and nodding of heads. When was the last time you put someone on the OR schedule, and they were scheduled, but then got canceled?’ Everyone started snickering and laughing. Then, I asked, When was the last time you ordered something from Land’s End and you got it and it was the wrong size or the wrong color? Or, When was the last time you ordered a book from Amazon.com and you didn’t get it, and you didn’t get a note that it was out of print or on back order?’"
All of the residents stood looking at him and no one nodded their head, he says.
The wake-up call delivered to the Boston residents was a smaller version of what the rest of the nation received courtesy of the Institute of Medicine’s report last year on medical errors in the U.S. health care system.1
Now, possibly more than ever before, medical professionals and the public are facing the unpalatable fact that this country’s health care industry tolerates levels of mistakes and inefficiencies other industries would deem unacceptable. The greater issue at question, it seems, is this ethical to patients?
Don’t focus on the error
To fix the problem, a growing number of medical experts say, hospitals and health systems should not be asking themselves, Who messed up?’ when mistakes are discovered, but instead, "How can we change the system so it doesn’t happen again?"
Health care as an industry has never embraced the concept of "systems thinking" that other industries have, argues Chessare. "We still have doctors showing up at hospitals every day and finding things broken and acting as if, Boy, we just need to find out who screwed up and give them a stern lecture and everything will be fine.’"
But on closer study of most medical errors, as in most mistakes in other fields, what may show up is that the cause is likely a number of small failures combining to make a big one, he says.
"Studies of bad outcomes in almost any industry show that very infrequently does something go poorly because somebody consciously acted to make it go poorly," he says. "It is usually a system breakdown. There are some bad apples out there, but they are few and far between."
Lessons learned from the government
Thirteen years ago, the Veterans Affairs Medical Center in Lexington, KY, started an unheard-of policy — they began disclosing their medical mistakes to patients and their families, often before the patients themselves knew something was wrong.
"We didn’t really envision it that way; it started smaller," recalls Steve Karman, MD, Lexington’s chief of staff. "I had just been named chief of staff, and we were trying to figure out how to do risk management.
"In the few years previous, our experience had been pretty bad, we lost a couple of cases that totaled about $1.5 million and we felt that, because the federal system allows patients two years to file a claim — and frequently patients wait until the end of that period to file — memories have faded, and it is very hard to defend the case," explains Karman.
They decided to put together a group of administrators, the hospital risk manager, quality assurance nurses, and the in-house attorney to look for evidence of problem cases.
"When we found one, we would look through the chart to see if there was a violation of the standard of care," he says. "If there was a problem, we would take testimony [from the caregivers involved] and write it down. When we felt comfortable that we had a complete dossier, the idea was to file it away in case we were sued."
Within a short period of time, however, they came upon a case they felt they couldn’t file away.
"We had a case where clearly a patient was killed by a medical mistake, the family had no idea and really could have no idea," he explains. "They had already left and the body had been claimed. So we were stuck there. We didn’t know it at the time, but, apparently, most hospitals would just sit on it. It’s the patient’s responsibility to file a claim. We didn’t feel comfortable doing that."
So, they called the family and asked that they bring a lawyer and meet with hospital officials. They did and the hospital told the family what happened. The case was quickly settled for $250,000. Since then, the hospital has adopted a policy of full disclosure of medical errors and acceptance of liability.
Errors now admitted
Once an error is discovered, hospital administrators inform the family or patient, admit the mistake, and accept responsibility.
"We also tell the patient or family they are probably due compensation and we help them apply for it," he says. "We will sometimes help them fill out the forms to sue us. And, we always advise them to get an attorney who specializes in malpractice claims. The point of all of this is we never make them the enemy, we don’t make them the adversary."
The response has been surprisingly positive, Karman has found. Once patients and families find out that the hospital is admitting wrongdoing and they won’t have to fight, the anger often is defused.
"We have had about five cases now over the past 13 years of patients who had died and the family really did not have an idea it was a malpractice issue," he adds. "We have settled all of these by admission. We have gone to trial only three times, twice on the merits, we won on one and lost one. The third one, we went to court for damages, because we could not come to a settlement. That was our biggest case, it was $341,000."
The policy has had other benefits, as well.
"The practitioners have been more willing to self-report themselves, as well," he says. "When they do something, they realize we are going to treat them fairly. We have never disciplined anyone for being involved in a medical mistake. Licensed practitioners risk being reported to the national practitioner databank and to the licensure boards. They know it, and don’t like it, but they understand it is a reasonable consequence for something that was pretty bad for the patient."
The hospital doesn’t fault the clinicians because again, says Karman, in most cases the mistake is the result of system problems.
"If you think a physician should never forget to do something, then it is never a system problem, it’s always the doctor’s fault," he says. "If you realize that all doctors are human, and I will include all nurses and pharmacists, too, the hospital has a responsibility to set up as many safety nets as possible to help people so that everything isn’t dependent on remembering one thing."
Focus on system flaws
The more open environment is key in allowing the facility to make needed strides in improving patient care, Karman believes. Because the hospital doesn’t waste energy and resources trying to hide its mistakes, but openly admits them, they are able to more efficiently repair the system flaws that caused the errors to begin with.
"In many cases, we are fixing the barn door after the horse is out, but we are fixing it," Karman emphasizes.
They have targeted errors by implementing a computerized medical record. The computer also allows managers to set up a system to "flag" certain things: exceptionally long hours by physicians, duplicate drug orders, and drug prescriptions with similar or confusing names, he says.
"It is becoming common knowledge that medical mistakes happen. What people are interested in is not so much that there are mistakes, but who is doing something about it and are the people responsible responding in a reasonable way," he says.
Real change in the health care system won’t take place until clinicians, nurses, physicians, physician assistants, and others are trained to see themselves as part of a team dedicated to achieving the best possible health care for their patients.
"For the most part, you have doctors; and to a lesser extent, nurses and other caregivers functioning as if they are the owners of the medical decisions around their patient, and sort of assuming that someone else was paying attention to issues of hospital systems," says Chessare. "They don’t see themselves as part of the system."
His hospital has an annual quality improvement initiative consisting of six elements that are changed each year. These improvement goals are published and distributed throughout the hospital and to people the hospital serves, he says.
Two years ago, as part of the quality-of-care element of the initiative, they decided to focus on reducing medication errors.
"We read up. We did our homework. We knew that the first step was getting all of the errors reported so that you could learn from them," he says.
The hospital changed its reporting system to allow anonymous reporting of errors, and their error rate jumped from eight or nine events per 1,000 days to 21. After studying the different events, they implemented system changes that brought the rate down to a real error rate of 10 per 1,000.
"Now, in a paper system, where doctors are still writing orders down on paper, that was not easy," Chessare notes. "It still isn’t good. It isn’t very reassuring to know that for every 1,000 days in the hospital there are 10 errors or near misses. But, we have created the culture of safety and we are running with that ball."
Escape entrenched attitudes
The hospital is implementing a computerized order entry system to make medication orders easier and reduce the likelihood of errors. But, the larger problem is the entrenched attitude among many in the health care system that solving problems only requires finding the right person to blame for a mistake and dismissing the person or people, he adds.
"Without the training of professionals in this type of systems thinking’ and teamwork, every time you start the conversation about a problem, some people come back with this, Oh, somebody is screwing up, let’s just find out who it is and get rid of them,’ attitude."
The same attitude leads to too many hospitals being satisfied with an error rate that is better than their peers or lower than what it used to be, he adds.
"What are the ethics of physicians who believe that they know something when they haven’t take the time to study it?" he questions. " I say all the time, Our mortality rate is 1.3 per 1,000.’ It is wonderful [because] it is better than most academic medical centers. But, why can’t it be 0.2? And, I hear, Oh, well, that could never be.’ Well, how do you know that?"
Reference
1. Corrigan J, Kohn L, and Donaldson M, eds. To Err is Human: Building a Safer Health Care System. Committee on Quality of Health Care in America, Institute of Medicine. Washington, DC: Institute of Medicine; 1999.
For More Information
The National Coalition on Health Care and the Institute for Healthcare Improvement have published a report, "Reducing Medical Errors and Improving Patient Safety: Success Stories from the Front Lines of Medicine." For more information, contact the coalition. Telephone: (202) 638-7151. World Wide Web: www.nchc.org. Or contact the Institute for Healthcare Improvement. Telephone: (617) 754-4800. World Wide Web: www.ihi.org.
Suggested Reading
• Smith R, Hiatt H, Berwick D. A shared statement of ethical principles for those who shape and give health care: A working draft of the Tavistock Group. Ann Intern Med 1999; 130:143-147.
• Glenville B. Safe health care: Are we up to it? BMJ 2000; 320:725-726.
• Berwick D, Hiatt H, Janeway P, et al. An ethical code for everybody in health care. BMJ 1997; 315:1,633-1,634.
Sources
• Steve Karman, MD, Veterans Affairs Medical Center, 2250 Leestown Road, Lexington, KY 40511.
• John B. Chessare, MD, Boston Medical Center, Boston University, One Boston Medical Center Place, Collamore 4, Boston, MA 02118-2393.
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