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Edward Harris
President of the medical staff Good Doctors, Bad Mistakes |
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During his presentation to the Deputy Chiefs' Committee and Medical Center Staff Task Force at Stanford Hospital in March, Larry Smith, the recently recruited director of risk management at UCSF Stanford, emphasized that physicians must develop a "culture of safety" in their professional lives. We must first acknowledge that all doctors make mistakes. We must acknowledge that the risk is there, constantly, for us to do harm to patients. The data clearly support this. Larry Smith presented data indicating that every day in the United States, 275-500 patients die because of an error on the part of their caregivers. The Harvard Medical Practice Study, published in the New England Journal of Medicine in 1991, reviewed more than 30,000 hospital admissions in New York State. The data showed that nearly 4 percent of patients in hospitals suffered complications from treatment that prolonged their hospital stay, resulted in disability, or caused death. Two-thirds of these complications were due to errors in care. Subsequent studies have confirmed these statistics in many other parts of the country and, obviously, we are not immune here at Stanford, although to my knowledge no institutional prospective study on this matter has been conducted here. As physicians, the first step is to accept these data as real and, rather than assuming that these events of bad practice are inflicted by inadequately trained physicians exercising poor judgement or technique, accept another reality: Good physicians make bad mistakes. Once this is internalized, we can all take steps to diminish risk for ourselves and our colleagues. Larry Smith noted that when a treatment error is made, we should be asking "Why?" not "Who?" As Atul Gawande, M.D., states in a New Yorker article on this subject, ". . . we can make dramatic improvements by going after the process, not the people." We have a long way to go to catch up to other industry standards. The aviation industry, for instance, has reduced operational errors to one in 100,000 flights, and most of those are trivial. In medicine, it has been the anesthesiologists who have looked at systems management to decrease errors and live up to the word in the center of their society's emblem: "Vigilance." Using "critical incident analysis," the anesthesiologists have redesigned equipment to make it more difficult to dial in the wrong gasses or give inappropriate medications (or the wrong doses) for emergencies. David Gaba, a member of our faculty in anesthesia at Stanford, has designed a patient simulator, a computer-driven mannequin that behaves like a real patient. The device can be programmed to develop shock, arrhythmias, airway swelling and other crises that both trainees and experienced anesthesiologists rarely contact, but which both must be ready to handle. Larry Smith urges us to view errors as opportunities to recognize a potential defect in our systems and to enable us to become involved in process re-engineering. More focus on preventing mistreatment of patients can give us what we need and want: satisfied patients without malpractice suits. |
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