We Need a Better System to Avoid Medical Mistakes

I saw a patient in the hospital awhile ago with a disease you probably haven’t heard  of—iatrogenesis imperfecta. ‘Iatrogenesis,’ in plain English, means that the illness was caused by medical intervention. Sometimes such complications of care are inevitable or idiosyncratic, like unexpected allergic reactions to medications. Sometimes they are preventable, or caused by human error. That is the ‘imperfecta’ part—no one is perfect, and we can make some very high-stake errors when we try to make people better.

In my patient’s case, he received a medication that was contraindicated given the multiple diseases he had. The situation was very complex—as it almost always is in the hospital these days—and no one anticipated the problems that might occur. The end result was a patient with organ failure who became one of the many people for whom modern medical care is fraught with error and complication.

In 1999, the Institute of Medicine issued a report on medical error titled “To Err is Human,” which called attention to this problem. The report concluded that on the one hand, high-tech medicine had become a victim of its own success: More procedures, more interventions, and more medications meant more opportunity for ill-fated combinations. And people who at one time would not have survived an initial illness were living long enough to require long hospital stays, leaving them vulnerable to hospital-acquired illnesses. On the other hand, health professionals were ignoring the most basic opportunities to prevent unnecessary illness, such as washing hands before seeing patients.

Since that report there has been a great effort to improve safety in hospitals. Some of it seems pedantic, designed to improve our documentation of what we do rather than our actual care. For instance, we now have a “time-out” at the patient’s bedside before doing a procedure, to confirm the identity of the patient. Then we document the check in a sticker placed in the chart. This is designed to make sure that we don’t do procedures on the wrong patient—an excellent goal. But when it comes down to it, I can’t imagine that people harried enough or distracted enough to contemplate a procedure on the wrong patient would be stopped by this sticker system (or prevented from making another error in the process).

Some interventions seem more useful to me, like the proliferation of sinks and alcohol soap stations throughout the hospital. It’s hard now to forget to wash your hands, and that is a great improvement.

Other changes that can make a huge difference include the implementation of computer systems to catch drug interactions and allergies, pharmacy stocking systems that don’t allow concentrated and potentially fatal doses of medications to be stored in one vial (necessitating nurses to properly dilute them before use), and rules that prevent the dispensing of medications that require intensive-care monitoring on wards that do not have those monitoring systems in place. Yes, you can teach 500 nurses that a medication is deadly in the concentration it comes in, but it would be more effective and safer to never allow that concentration on  the hospital floor in the first place.

The patient I saw recovered, but others do not do so well. The frailer, older, and sicker patients are at the greatest risk. We have to recognize what the Institute of Medicine’s report highlighted: Safety cannot be achieved by well-meaning individual doctors or nurses who are, at bottom, human. It requires hospital systems that help us avoid making terrible mistakes.

(PHOTO: GETTY IMAGES)

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