An interesting story came across my desk recently. Apparently, some states in the U.S. have moved towards a punitive model in trying deal with medical errors and adverse outcomes – this particular story describes how Utah will no longer fund healthcare providers and hospitals for dealing with illnesses that resulted from avoidable errors and infections.
On the surface, it kind of makes sense – one should be punished for making a mistake, right? Other goods and services industries guarantee their work, so why not medicine? But here’s the kicker: since June 2011, when medical errors were “mandated” to be reported, only 17 such events have been disclosed in the whole state of Utah that would potentially fall under this punitive model.
There is absolutely no way that there were only 17 avoidable medical errors in the whole state of Utah over the course of a year.
As discussed in an earlier post, in reality healthcare professionals make mistakes. Daily. Medicine is still very much a skill-based profession, and as such is at constant risk for human errors. It is normal. The trouble is, identifying and preventing them is a very complex issue; a process that is still very much in its infancy in the medical field.
The first difficulty is in recognizing when errors occur. Most mistakes made by healthcare professionals go unnoticed because they usually do not lead to an appreciable adverse outcome. Some of you may be familiar with the swiss-cheese model of adverse events; because of the multitude of steps involved in a patient’s care (i.e. different levels of “safeguards”), it usually takes a series of errors to align before an adverse outcome materializes.
Imagine this scenario:
A cancer patient presents to a busy oncology clinic for assessment and initiation of chemotherapy treatment. The physician writes an order for the chemotherapy drug, but the handwriting is suboptimal and it is difficult to make out where the decimal point is in the dosage: is that 0.10 or 1.0? The nurse happens to be a new nurse, who decides to ask a more senior nurse to help decipher the writing, since the physician is already swarmed with an overflowing list of patients. They agree that it most likely is 1.0, and the nurse goes on to set up the infusion pump. Incidentally, the hospital has just switched to a new vendor for its infusion pumps, and all the staff are just learning how to program the machines. The nurse unintentionally enters a dose of 10.0, which is well above the normal limits of this particular chemo – however the machines were not designed to have automatic safeguards to prevent programming of excessive doses. The patient ended up receiving 100x the intended dose of chemotherapy, and passed away shortly after the error(s) were identified too late.
Who’s at fault here? And if it’s more than one individual, how much of the “blame” should each be accountable (and perhaps punishable) for? We now enter the next great difficulty in trying to use a punitive model to address medical errors: the complexity of how errors occur in medicine means that true analysis of them require honest self-reflection and reporting. In other words, the culture of how we view and approach medical errors must first shift away from the traditional shame-based paradigm (check out Brian Goldman’s excellent TED talk on this topic).
And this can only happen in a safe and protected environment (such as morbidity & mortality rounds), where medical mistakes can be openly discussed without fear of litigation and punishment so that everyone can learn from them. Otherwise things will only get swept under the rug, and you end up with ridiculous numbers like 17 errors in a whole year.
Punishing hospitals and healthcare providers for adverse events will, in my mind, only drive us in the wrong direction in tackling and preventing future medical errors.