Preventable Medical Errors

In 1999, the Institute of Medicine’s report, “To Err Is Human” found that as many as 98,000 Americans die every year from preventable medical errors. Since the time of that landmark study, efforts have been made to improve patient safety. However, a recent study shows preventable complications are way too frequent in American health care. The study, conducted from 2002 to 2007 in 10 North Carolina hospitals, found that harm to patients was common and that the number of incidents did not decrease over time. North Carolina was chosen for the study because its hospitals compared with those in most states and also have been involved in programs to improve patient safety. “It is unlikely that other regions of the country have fared better,” said Christopher P. Landrigan, the lead author of the study and an assistant professor at Harvard Medical School. Most of the medical problems were temporary and treatable, but some were more serious, according to the recent study. The study found that 2.4% caused or contributed to a patient’s death. Many of the problems were caused by the hospital’s failure to use measures that had been proved to avoid mistakes and to prevent infections.

Books recently published by Harvard’s Dr. Atul Gawande (The Checklist Manifesto) and John Hopkins’ Dr. Peter Pronovost (Safe Patients, Smart Hospitals) are calling on doctors and hospitals to institute checklists modeled on the aviation industry to improve safety. According to Pronovost, by using simple checklists, you look for the most important safety measures and can find a way to make them routine. Another reason for medical errors is a hierarchy culture that is immersed in intimidation, where doctors tend to rule supreme over nurses, technicians, and other staff. In his book, Pronovost describes a situation when he was working as an anesthesiologist.   He witnessed a surgeon who refused to switch from latex to non-latex gloves during an operation, despite Pronovost’s concern that the patient was having a potentially fatal latex-allergy reaction. It was only after a nurse decided to call the hospital president that the surgeon acquiesced. As Pronovost explains, “a patient’s death could have been caused by a lethal combination of ignorance and arrogance.” Luckily, for this patient, the nurse spoke up, however many times nurses and other staff members are too scared or intimidated to speak up.

Another problem is that medical schools are failing to teach future physicians the most pressing lessons about why mistakes happen and how to prevent them. Students need to be trained to work as a team with nurses, pharmacists, and other staff members. According to Denise Murphy, vice president for quality and patient safety at Main Line Health System, “a breakdown in communication and collaboration can lead to horrible events that result in harm or death.” With efforts to make hospitals safer falling short, changes need to be made. The extra treatment required as a result of the injuries could cost Medicare several billion a year. Until patient safety improves, people will need to assist in protecting themselves against medical errors. It is important to question hospitals and find out what their infection rates are or if they use a checklist system. You need to be your own advocate.