Wednesday, November 21, 2007


Medical errors and mistakes can be due to process flaws and are easily correctable. Process defects are the usual cause of the most glaring mistakes that make media headlines. The mismatched heart transplant at Duke University in 2003 and the death of Boston Globe journalist Betsy Lehman in 1995 were due to process flaws. But most medical mistakes are not due to poor process design.

Most medical errors are due to individual and organizational characteristics. These are:

1) The God Complex of management. "Mistakes do not occur in our organization/practice/hospital. We got rid of all the incompetents years ago. We only have the finest, board certified ..." This is simple naivete' and should not be tolerated. Humans are never perfect, and never will be. An environment that recognizes imperfection and supports efforts to talk about errors without blame is a requirement for reducing mistakes. The need for tort reform to allow physicians and nurses to own up to their falability is obvious.

2) Distraction. The attention of doctors, nurses and other clinical workers should be focused upon the patient in front of them. The healing environment must be quiet, esthetically pleasing and safe. The noise in the modern hospital is intolerable - fire, bomb threat, abduction, an agitated and threatening patient and other types of alarms; iv alarms; EKG alarms and other patient monitoring devices that substitute for bedside nursing care; carpet and floor cleaning machine noise; meal carts with squeaking wheels, and on and on. All of these extraneous sounds distract direct caregivers from their focus upon one patient at a time. A distracted nurse in the process of giving a patient medication or a distracted doctor writing medication orders for a patient is a prima face' cause of mistakes.

3) Interruption. Focused upon a patient, the doctor is frequently interrupted by a nurse, dietitian, discharge planner, etc. Losing his train of thought, the doctor makes an error. If the error is discovered before reaching the patient - called a "near miss "- then the doctor is interrupted again to correct his error! If the doctor refuses to be interrupted, then recrimination is the rule. An 'Incident Report' is made out and works its way through numerous committees. The final result is an adverse comment placed in the doctor's file, "He is not cooperative, demeans ...(nurses, lab techs, etc.), and doesn't communicate well; is disruptive." This is the prototype of the modern health care organization, self-centered. This is not patient-centered care.

4) Haste. Modern hospital care is rush, rush, rush. Throughput is the rule. Get the patient in ASAP, evaluated and treated ASAP, and discharged ASAP. Patients are treated in a shotgun approach. Very little thought goes into the patient. Order tests and drugs and get the patient out--ASAP! Diagnoses and treatments are based upon test results. Patient-centered care requires time; time to communicate with the patient. But there is no time--order tests and drugs--and get the patient out ASAP! The cause is Medicare DRGs or payment by diagnosis rather than by individual service. Commercial insurers also dictate the number of days patients are hospitalized by denying payment if something is not being done to the patient--never mind for the patient. And doing to the patient is tests, surgeries and intravenous drugs and fluids. There is no time to evaluate the effects of the tests and drugs. Just get them done ASAP and get the patient out ASAP to make room for a new patient. Profit is determined by the volume of patients put through the system, not by quality of product--a satisfied and helped patient. Mistakes abound in this environment, when there is no time to think about the ONE patient at a time we are supposed to.

5) Multi-tasking. There is no harm while I coo my cat, type this blog, move the wash to the dryer and hang up the dried clothing. Multi-tasking during patient care is dangerous in and of itself. Multi-tasking on more than one patient at a time is a death wish. Hospitalized patients have multiple chronic diseases, four or more medications taken on a regular basis for those diseases; and now an acute problem requiring more therapy- more drugs. It is easy to confuse the two patients with heart failure or sepsis that are on your service. Responding to an overhead page or beeper while involved in the care of one patient is multi-tasking - dangerous for both the immediate patient and the one you are being paged about.

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