Why we need a systems approach to prevent deadly medical errors
We've all heard sensational stories about egregious medical mistakes, such as surgeons amputating the wrong limb. What I only recently began to realize is the sheer number of medical errors that are made every day.
A growing body of literature on patient safety is shedding light on the frequency and magnitude of medical errors such as adverse drug events and mix-ups in laboratory and radiology reports. A recent article in the British Medical Journal estimated that in hospitals across the United States, 120,000 people die each year as a result of medical errors. That's more than the number of fatalities from automobile accidents, breast cancer and AIDS combined. If you find that figure shocking, you're not alone. Were it not based on documented research, I too would have been hard pressed to believe this could be true.
While most errors can be prevented, we won't find a real solution until the culture of medicine changes. Physicians have traditionally maintained quality by setting high standards for their profession, from the demanding criteria for entry into medical school to ongoing expectations for CME and self-critique. This expectation of excellence and infallibility, along with the fear of raising malpractice liability, has discouraged physicians from publicly disclosing errors.
A systems approach
What can we do to improve patient safety and eliminate harmful errors? The answer, I believe, lies in taking a step back and looking at the big picture. We do not practice in isolation, but as part of a larger system of care. It is this system that we need to change to better protect patient safety.
Medicine can learn from the airline industry, which avoids finger pointing when accidents occur.
An adverse drug event, for example, is likely to involve many components of the health care system and include the pharmacy, nursing staff and patient, as well as the prescribing physician. At each stage, there is an opportunity to head off disaster.
The information systems in many pharmacies today are equipped with software that identifies and alerts pharmacists to serious drug interactions. This can be a powerful tool, but it only works if the system is tracking all the medications a patient is taking. Often, patients under the care of several doctors for many different conditions focus only on the condition at hand and forget to mention other medications to physicians.
To address these types of situations, the health care team could modify admission and history forms or specifically query patients about prescriptions from other physicians. That information could be transferred into the pharmacy system, and an alert could be transmitted back to the prescribing physician.
Lessons from industry
To reduce medical errors, we need a new way of thinking, one that lets go of the notion of individual physician control in favor of health care system accountability. Some of the best examples of this new way of thinking come from industry.
Under the guidance of the Federal Aviation Administration, the airline industry has adopted a systems approach to identify and remedy errors. Instead of pointing fingers at pilots or other individuals when errors occur, the industry conducts a detailed investigation in which the many behind-the-scenes processes and protocols that led up to the failed flight are mapped out.
Everyone from the ground crew to the air traffic controllers is encouraged to help identify and solve the problem. This systems approach to fixing problems has led to an impressive safety record. In 1998, not a single death occurred in commercial aviation in the United States.
Primum non nocere
As part of its larger Quality of Health Care in America initiative, the Institute of Medicine will soon publish a report on patient safety. The College is planning to use this document as the basis of a new policy initiative in which we will try to draw attention to the issue of patient safety.
The College cannot correct the problem of medical errors single-handedly, but by collaborating with other organizations, we can begin to find ways to reform the heath care systems in which we operate.
As physicians, we need to be the driving force to bring about change. We can help the entire health care system to embrace one of our fundamental principles: primum non nocere. And so I urge you to change your way of thinking and work with the other members of your team to make health care safer for all.
As always, please share your thoughts with me at firstname.lastname@example.org.
—Whitney W. Addington, FACP
Patient safety on the Web
AMA's National Patient Safety Foundation (www.ama-assn.org/med-sci/npsf) includes a bibliography of articles on patient safety from medical journals and the mass media, as well as reports, book reviews and a public opinion poll.
Institute for Safe Medication Practices (www.ismp.org) offers articles on medication errors and a form for providers to report errors.
FDA Medwatch program (www.fda.gov/medwatch/) provides information about the FDA's medical products reporting program and encourages health professionals to monitor and report adverse events and problems.
American Society of Health System Pharmacists (www.ashp.org) includes a section on "medication misadventures."
Aviation Safety Reporting System (olias.arc.nasa.gov/ASRS/ASRS.html) includes an overview of the airline industry's anonymous reporting system.
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