What Can Be Done about Medical Errors?

By Michael Wong, JD (Founder/Executive Director, Physician-Patient Alliance for Health & Safety) and Nicholas Wong (Director, Patient Safety Analytics, PPAHS)

Editor’s note: This article was first published in TheDoctorWeighsIn. It discusses recent research showing that medical errors constitute the third leading cause of death in the US and the need to develop high reliability in hospitals.

A new study published in the British Medical Journal by Martin A Makary, MD, and Michael Daniel, MD (both from the Department of Surgery at Johns Hopkins University School of Medicine) estimates that more than 250,000 deaths due to medical error occur in the United States alone.

Numerous news agencies have reported on this with the headline “Medical error third leading cause of death in United States”. What’s more alarming than the news that a profession dedicated to making us better is doing the exact opposite (albeit by accident), resulting in patient deaths?

Patients expect perfection from their professionals. However, is this a reasonable expectation?

Toll of Medical Errors Source: http://well.blogs.nytimes.com/2009/07/09/for-doctors-the-personal-toll-of-mistakes/?_r=0
Toll of Medical Errors Source: http://well.blogs.nytimes.com/2009/07/09/for-doctors-the-personal-toll-of-mistakes/?_r=0

Doctors make mistakes

In a 2012 TED Talk titled “Doctors make mistakes. Can we talk about that?”, Brian Goldman, MD draws a comparison to baseball—a baseball player batting 400 average is grounds for being in the Hall of Fame, yet anything short of 1,000 is unacceptable for members of the medical profession. He then advocates for a system to openly discuss, assess, and take action upon these mistakes to reduce those mistakes from ever being repeated.

The question is, how can the healthcare system reduce errors that result in patient deaths?

To reduce patient deaths, hospitals need to become “highly reliable” organizations. As Dev Raheja, MS, CSP, an international risk management and quality assurance consultant for the healthcare, medical device, and aerospace industry, writes:

“Hospitals are still far from being highly reliable…Medical education usually does not cover the theory of reliability. One cannot blame hospitals to be going in different directions. The Institute of Healthcare Improvement (IHI) has taken the initiative to apply industry methods of system reliability to healthcare systems. It defines reliability as “failure-free performance over time”. This is simple enough to be understood by anyone. The aim is to have no failures over an extended time period in spite of variability in the patient environment.”

In the article “High-Reliability Health Care: Getting There from Here”, The Joint Commission President and CEO, Mark R. Chassin, MD, MPH, and executive vice president for healthcare quality evaluation, Jerod M. Loeb, Ph.D, urge hospitals to become more reliable:

“…too many hospitals and healthcare leaders currently experience serious safety failures as routine and inevitable parts of daily work. To prevent the harm that results from these failures, which affects millions of Americans each year, the article specifies a framework for major changes involving leadership, safety culture, and robust process improvement. This framework is designed to help hospitals make progress toward high reliability, which is the achievement of extremely high levels of safety that are maintained over long periods of time—safety comparable to that demonstrated by the commercial air travel, nuclear power, and amusement park industries …

These changes involve the leadership’s commitment to achieving zero patient harm, a fully functional culture of safety throughout the organization, and the widespread deployment of highly effective process improvement tools.”

Speaking about his own research, Dr. Makary says that human error is inevitable and that systems need to be in place to minimize error.

“Human error is inevitable. Although we cannot eliminate human error, we can better measure the problem to design safer systems mitigating its frequency, visibility, and consequences. Strategies to reduce death from medical care should include three steps: making errors more visible when they occur so their effects can be intercepted; having remedies at hand to rescue patients; and making errors less frequent by following principles that take human limitations into account.”

In other words, there needs to be a better system in place to capture and track the data associated with medical errors, which will, in turn, drive the creation of better practices to improve patient safety. Sadly, there is less room for innovation in the business of health. “There is a strong moral case for innovations in this area, but there isn’t really a financial case for hospitals to improve this system the way it is”, says Dr. Makary.

The financial case

The good news is that the financial case is being built, albeit indirectly. For now, it is being driven by the world of insurance claims with the dollar value of a human life being determined by litigation. In a May 2, 2016 press conference presented by the Physician-Patient Alliance for Health & Safety, the average payment per claim for opioid-related adverse effects alone was between $210,000 and $330,000.

In the field of opioid-related sedation, hospitals have been able to prove a positive economic case for the implementation of continuous patient monitoring standards. In one case study, adding capnography monitoring to current standard of care (including pulse oximetry) allowed the St. Joseph/Candler Hospitals (Savannah, GA) to experience more than 10 “event free” years of patient safety, resulting in an estimated $4 million savings (not including potential litigation costs) and a 5-year return on investment of $2.5 million.

This has been furthered by economic modeling conducted by Rhodri Saunders, DPhil (health economist at Ossian Health Economics and Communications in Basel, Switzerland) as related to the field of procedural sedation for endoscopic procedures. In a recent Anesthesiology News article, “Modeling Shows Potential Cost Savings With Capnography Monitoring,” Dr. Saunders found that implementation of capnography to enhance continuous patient monitoring led to a reduced incidence of adverse effects which in turn led to an average cost savings of $85 per procedure ($156 vs $241 with standard of care).

The research by Drs. Makary and Daniel highlights that there is an underlying systemic issue with how we capture data related to adverse events, synthesize insights, and develop business cases that support the moral impetus for keeping patients safe.

Thankfully, the work has begun and the incremental change needed to be made in our hospitals has started.

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