When medicine hurts

Dec. 3, 2018 / By Steve Delaronde

Between 2011 and 2013, 31 out of 38 patients treated by the same neurosurgeon in the Dallas area were left paralyzed, seriously injured or dead. The neurosurgeon became known as Dr. Death. This is an extreme example, but it serves as a reminder that reducing medical errors and improving patient safety must remain a top priority.

Medical professionals represent a subset of the population with specific training in the diagnosis and treatment of disease. Some medical professionals are better than others, all are human, and therefore subject to making mistakes. We trust healthcare professionals and the facilities in which they work to make important decisions that affect our minds and bodies. Because of this, we expect more from healthcare professionals than we might from others. In health care, unmet expectations can mean the difference between life and death.

Patient safety wasn’t addressed on a wide scale until the Anesthesia Patient Safety Foundation was launched in 1985. It has now been nearly 20 years since the Institute of Medicine estimated that up to 98,000 patient deaths were caused by medical errors in To Err is Human: Building a Safer Health System in 1999. The IOM then published Crossing the Quality Chasm in 2001. Despite this, medical errors are now the third leading cause of death in the United States and responsible for more than 250,000 deaths according to a 2016 BMJ study.

Mistakes are inevitable and part of the human condition. However, the solution may also lie in something that is also very human—communication. Here are a few examples of where improved communication among healthcare teams and between healthcare professionals and patients can make a difference:

• Morbidity and mortality for patients undergoing noncardiac surgery was reduced by almost 50 percent when a 19-item surgical safety checklist designed to improve team communication was implemented.
• Improved communication was cited in a 2016 JAMA article as a high-priority area for reducing potentially preventable readmissions.
• A 2015 CRICO report found that 30 percent of medical malpractice claims involved a communication failure.

While the exploits of healthcare professionals like Dr. Death get media attention, medical errors are typically the result of normal human errors and not poor judgment or recklessness; and they occur at all levels of care, not just surgery. The reporting of medical errors must be treated with the same level of seriousness and transparency that exists with the aviation industry. A dual system of medical error reporting should include 1) a mandatory reporting requirement for serious events and 2) a voluntary confidential reporting system for all other events and “near misses.” Greater transparency and mandatory follow-up and action is the next step.

Unfortunately, patients are not always clear if an adverse outcome was caused by a medical error or a simply a result of the inherent risk of medical procedures.  Patients trust their providers to do the right thing and do not often consider questioning their decisions or outcomes. Similarly, physicians and nurses do not consistently report errors, citing fear, an unsupportive attitude of administration, barriers related to the system, and the employees’ own perceptions of what constitutes an error as major issues.

Ultimately, patient safety must start within the physician’s office or hospital, but it can’t end there. Self-regulation and building a culture of safety that includes safety checklists, communication between medical professionals, and supportive systems for receiving patient input will have a profound impact. However, these approaches must be developed and maintained along with regulation, mandatory reporting, transparency, and consequences for not following safety procedures if we are to achieve lasting change.

Steve Delaronde is director of consulting for populations and payment solutions at 3M Health Information Systems.