Infinite Chances To Kill Us

Healthcare puts you at risk: there are infinite opportunities for mistakes that can harm even kill you while you are awaiting the promised cure.

The problem really struck home to me yesterday while receiving sign-out – transfer of the responsibility for the patients – from one of my colleagues.

  • The patient who was given the right medication but by vein rather than orally.
  • The one with a cardiac pacemaker scheduled for an MRI (that would have damaged the pacer) stopped at the last minute because of an accidentally overheard conversation.
  • The “routine” catheterization that became a nightmare because there was no place to put the catheter.
  • A constantly crying baby whom the nurse tried to console with a binky, not knowing the child was in pain from jaw surgery.

None was seriously injured by these “mishaps,” but they could have been. None was as dramatic of the death of a British cancer patient immortalized in the London Times (2001) or the $10 million lawsuit over the Pennsylvania baby who died from a ten times overdose of heart medication digoxin. Each error was preventable or avoidable. There was no safety system.

A recent push by the Commission that governs hospital accreditation is for a “Culture of Safety.” They mean well but they miss the fundamental point. Most medical mistakes are due to either: (1) Lack of knowledge by medical science, and/or (2) Mistakes made by humans because humans are not perfect.

(1) You cannot legislate new knowledge. That comes only in a learning environment, which we do not have but desperately need.

(2) You cannot legislate human perfection. Nurses and doctors will make mistakes because they are human and [here is the key point] those mistakes will hurt you because there is no safety system to stop them before they happen. The pilot of an airplane literally cannot raise the plane’s wheels while it is on the ground. The system won’t let him.

In healthcare, there are too many people involved. Too many pieces of information. Too many handoffs or sign-outs. Communication is ineffective, and is constrained rather than enhanced. The exploding number of drugs increases the chance of a bad interaction or a wrong dosing. The expanding number of procedures increases the probability of judgment or technical error. The morass of rules and regulations – the incredible complexity – increases chance of a mistake.

Think about your care. Who is more likely to give you safer and better care: a consistent, single “non-expert” generalist doctor, or a number of constantly changing specialist experts writing orders at the same time? I hope that was a rhetorical question. The way medicine is currently structured, none of us has the safer option.

We cannot depend on people being perfect, and “culture” (as in Culture of Safety) means people. We need a System for Safety. Such a system would flash a big red warning DANGER sign when someone tries to: schedule an MRI in a patient with a heart pacemaker; schedule a routine surgery in a child with a congenital airway problem; give the wrong drug or the wrong dosage of the right drug (remember Dennis Quaid’s twins?) to a patient; give two drugs that are incompatible or to which the patient is allergic; operate on the wrong coronary artery (ask Dana Carvey, the comedian); etc, etc, etc.

A “Culture of Safety” won’t keep us safe.
We need a System
for Safety.

System MD

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2 comments ↓

#1 Marcela on 10.24.12 at 3:24 am

They should praitivze fire departments too. Charge the citizen, business owner every time they put out a fire. They should charge for the amount of water used, the amount of gas, axe swings, times they had to drag a body, if they get a flat tire on the fire engine the homeowner will get a bill for that too. At he end of the day, they can say the house was a total loss, but can you sign here, here and here? You can pay the $30,000 bill in increments of your choosing, have a nice day.

#2 travis on 07.27.14 at 7:10 pm

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