Volume 24 • No.1 • January 2000

Bauer appointed to reconfigured vice president's post;
dean sought

Doctors can help spur health legislation,
says Eshoo

Facilities upgrade planned for medical school facilities

 

 

To Err is Human

byx M A R T I Nx I.x B R O N K

Recently, the subject of medical errors became front page news with the release of the Institute of Medicine (IOM) report: To Err is Human: Building a Safer Health System. According to two studies referenced in the report, medical errors may lead to somewhere between 44,000 and 98,000 hospital deaths per year. The majority of these errors, the report maintains, derive from basic flaws in the organization of the health care system, not from "individual recklessness."

I think all of us would agree intuitively with the premise that we try to do our best in an imperfect system. In spite of the tremendous technological advances in recent decades, we often still function with inadequate information in an incompletely monitored environment. We make mistakes, some of which might be avoided if better controls were available.

Medication errors are illustrative of this problem. They account for an estimated 7,000 deaths per year. Complications result from illegible prescriptions being misinterpreted, drug concentrations being miscalculated or allergies not being properly recorded. The IOM suggests that many such problems could be prevented with better management systems.

But while technology will afford some of the solutions, clearly human error cannot be eliminated by automated control mechanisms. We still will make misjudgments and technical errors, and we still will suffer from interpersonal communication lapses.

How we respond to these errors will have ongoing significance on our growth as physicians. It is imperative that we find ways to maximize what we learn from our mistakes. This means not simply reflecting on our own errors but openly reviewing problems together. Our group forums such as the departmental morbidity and mortality conferences need to be both comprehensive and supportive. Furthermore, we should communicate freely across disciplines to better understand issues that have complex origins. In this regard, I am pleased to report that the Stanford Hospital Care Review Committee recently decided to expand its impact by regularly disseminating its findings related to problematic patient care issues.

As we pursue such self-improvement efforts, we repeatedly return to the pivotal role of proper communication. Discussions after the fact may be valuable for learning, but effective patient care demands that we focus on enhancing communication prospectively. We must ensure mutual understanding and timely exchanges among all the potential participants of a patient's health care team. Indeed, the IOM report points to inadequate communication as one of the sources of medical errors, and many of us have experienced the problem directly. For me as a surgeon, one of the more uncomfortable situations I can face is to be called in to assist in the care of a desperately ill individual only after all other medical options have been exhausted. In that circumstance, we lose the opportunity for prospective dialogue, and the result may be a truly sub-optimal outcome.

The IOM report calls for a change in our approach that will build a "culture of safety." One mechanism it prescribes is to establish mandatory and voluntary reporting systems for medical errors. The Department of Veterans Affairs instituted such a policy for its hospitals in June 1997, and it has just released a report documenting some 700 deaths due to medical mistakes in the first 19 months of its monitoring.

The IOM believes we can reduce our error rate at least 50 percent over the next five years. Our leaders in Washington, D.C., already have seized upon the IOM's recommendations and have offered us a new bureaucracy to address the problem. Hopefully, we can implement the initiative ourselves and create significant new solutions to this intrinsic dilemma of error in medical practice.

martin.bronk@ucsfstanford.org

 
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