Friday, August 10, 2012

Medical errors: to err may be human, but we need systems to decrease them

An op-ed by Sanjay Gupta, MD, the Atlanta neurosurgeon and CNN medical correspondent, appeared in the New York Times on August 1, 2012. “More treatment, more mistakes” makes the case that medical errors are common and that they are largely due to the pressure to “do more”, to do more tests, to do more x-rays, to do more surgery. This is not news in itself; the Institute of Medicine (IOM) of the National Academy of Sciences published its study “To Err is Human” in September 1999, observing that between 44,000 and 98,000 deaths occurred per year as a result of medical errors (full text available at

To Err is Human itself was not the beginning of the study of medical errors. It uses a taxonomy dividing errors into “Diagnostic”, “Treatment”, “Preventive” and “Other”, published 6 years earlier in a study by Lucian Leape, et al., in the Quality Review Bulletin.[1] To Err is Human detailed the variety of types of medical errors that could occur, the relative frequency with which they occurred, and the reasons why they occurred, and provided suggestions as to how to prevent them from occurring. The Institute for Healthcare Improvement (IHI), founded by Leape and former CMS director Don Berwick (who were among the authors of the IOM report) has been working on this issue for more than 25 years. Its “100,000 lives campaign” sought to save that many lives by having hospitals sign on to implementation of certain strategies that had been shown to reduce errors. These included “timeouts” in surgery to be certain that everything was correct (right patient, right part of the body, etc.) before beginning, particular ways of managing people on breathing machines in intensive care units to prevent “ventilator associated pneumonia”, and the like.

A key point is that very few of these errors are intentional – they are not malpractice in the traditional sense, they are rarely the result of physicians being “bad doctors” – and yet people, avoidably, die from them. A key part of the strategies promulgated by people like Berwick and Leape, IHI, by the IOM report, and others working in the field is to employ the systematic approach to error reduction developed in other industries, such as airlines. (A common trope is that if airlines had errors as frequently as medicine, a jumbo jet full of people would be crashing several times a day.) Continuing follow-ups have looked a “how we are doing”, such as in “Five years after ‘To err is human’: what have we learned?” by Leape and Berwick in JAMA in 2005[2] and the summary of it by the Commonwealth Fund.

It is in the context of this history that Gupta’s article appears. Its main significance is that it brings to public (New York Times) attention the fact that these problems still exist, and that despite progress (and there has been much) there is much that still needs to be addressed. It is a balanced presentation, but does emphasize the point in the title – that more treatment leads to more errors, or, to put it another way, that more is certainly not always better. He cites “Rule #13” from the novel “House of God”, written by Stephen Bergman, MD (under the pseudonym Samuel Shem) in 1979: “The delivery of medical care is to do as much nothing as possible,” a restatement of the dictum primum non nocere, first do no harm.

An interesting series of letters responding Gupta’s paper appeared under the heading “Taking steps to reduce medical errors” in the Times on August 4. One of them is from Bergman, who echoes Gupta’s concept that fear of malpractice suits (the “whining motor behind doctors’ ordering unnecessary, pricey tests,”) is the cause of many errors, and applauds interventions such as surgical time outs. However, another letter, from Niall O’Dowd, the uncle of Rory Staunton, the 12-year old boy who died after being treated for a “minor” scrape in the NYU Hospital emergency department (see Jim Dwyer, “An infection, unnoticed, turns unstoppable”, NY Times July 10, 2012 and many follow-up articles including a column by Maureen Dowd “The boy who wanted to fly”, 3 days later), points out that there are also dangers, as in his nephew’s case, from doing too little.

Mr. O’Dowd focuses, naturally, on the emergency department, which is where his nephew was treated, inadequately as it turns out. Emergency departments are seeing more and more patients, and are responsible for a very large and increasing number of admissions to hospitals, as detailed in a recent New England Journal of Medicine article by Schuur and Venkatesh, “The growing role of emergency departments in hospital admissions”.[3]  They identify a number of trends that tend to increase the use of the emergency room as a source of care, particularly for acute conditions. These include the lack of availability of acute-care appointments in primary care practices, and the lack of the high-tech instruments such as CT scanners that permit EDs to rapidly diagnose and admit – or rule out and then discharge – conditions such as heart attack and stroke.  They also include public education campaigns that urge people to go to the ED when they have symptoms that could be heart attack or stroke, and, of course, the fact that lack of insurance prevents people from accessing health care in most other settings (federal law requires EDs to assess anyone who presents there). While the fact that the increase in admissions from the ED may have something to do with their “lower threshold” (“…emergency physicians are trained to assume the worst and are more likely to admit patients with uncertain diagnoses and with whom they don't have an ongoing relationship, and that they are unwilling to discharge patients when they cannot guarantee outpatient follow-up,”) it is also possible that in their pressure to diagnose and admit the most sick, they could possibly undertreat some, like Rory Staunton, who do not appear to be so ill.

Mr. Staunton may have benefited from antibiotics he did not get. Other letter writers speak of both the dangers of underusing antibiotics and overusing them; however, the settings they describe (critical care units in the first case, treating viral syndromes in the second) are very different. Doing a lot is not necessarily wrong, or right. Doing little is not necessarily wrong, or right. Both can cause errors, and both can save lives. Yet a fifth letter writer suggests “our mission is clear: if it’s right for the patient, it’s the right thing to do.”

This is true as far as it goes; the difficulty is in ensuring what is right for the patient. But systems, checklists, timeouts, and consistent rules can go a long way to making this be the case. And if people with non-acute, non-emergent conditions can get in to see their doctors, and as important, have doctors and can have the health insurance that allows them to be seen, it would help even more.

This is something that we must not lose sight of; as Schiff, Bindman, Brennan et al note in a 1994 JAMA article, denial of care is the “gravest of all quality defects.”[4]

[1] Leape L; Lawthers A, Brennan, T, et al. ,“Preventing Medical Injury”. Qual Rev Bull. 19(5):144–149, 1993.
[2] Leape L, Berwick D, “Five years after to err is human: what have we learned?” JAMA. 2005;293(19):2384-2390
[3] Schuur JD, Venkatesh AK, “The growing role of emergency departments in hospital admission”, NEJM 2Aug2012;367(5):391-3.
[4] Schiff G, Bindman A, Brennan T, et al., “A Better-Quality Alternative: A Single-Payer National Health System Reform”, JAMA. 1994;272(10):803-808.

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