TOPICS > Health

Medical Mistakes

March 26, 2001 at 12:00 AM EDT


ACTOR: Are we out of hold yet?

ACTOR: Uh, no, we’re just going down to 8,000.

SUSAN DENTZER: A recent performance of a play about airline disasters had the audience mesmerized.

ACTOR: I knew we were going to do that.

ACTOR: It’s all right, I got it.

ACTOR: Okay, nice and easy.

ACTOR: It’s not going to keep it at 180?

ACTOR: Okay, mellow it out. Mellow it out!

SUSAN DENTZER: Called “Charlie Victor Romeo,” the play is based on actual transcripts of cockpit conversations before planes crashed.

ACTOR: Oh God!

SUSAN DENTZER: When it played at a New York theater, pilots in the audience raved about how well the production captured the human dynamics leading up to crashes. Here at this conference, the audience consisted of several thousand doctors, nurses, and other health professionals. They were watching the play for similarities between airline crashes and mistakes in health care.

ACTOR: We’ve got an emergency!

SUSAN DENTZER: In fact, the members of the audience said the confusion, tension, and noise of the airline crash scenes reminded them all too much of this.

EMERGENCY SCENE: Hold two. We have a 54-year-old white female.

EMERGENCY SCENE: No paramedics are available.

SUSAN DENTZER: Chaotic scenes like this one set the stage for medical mistakes, a major problem in healthcare. A high-profile 1999 study by the Institute of Medicine estimated that between 44,000 and 98,000 people die each year from errors committed in U.S. hospitals alone. And in February of this year, the IOM released a new study calling for a health system overhaul.

DR. DONALD BERWICK: We are saying that the care is not satisfactory. We are saying that the care the American population gets is not the care they should get.

SUSAN DENTZER: Dr. Donald Berwick heads the Boston-based Institute for Healthcare Improvement. He is one of the experts who participated in both of those Institute of Medicine Studies.

DR. DONALD BERWICK: We’re also saying it is not a matter of the effort or the will or the skill or the dedication of the American clinical community. They are wonderful. If the doctors and nurses weren’t trying as hard as they are, we’d be in a lot worse shape. What we’re saying is they need help. The American physician and nurse cannot now, alone, without redesign of the system, give the care they want to give. The game is over.

SUSAN DENTZER: And that’s why Berwick’s Institute for Healthcare Improvement brought the cast and production of the play “Charlie Victor Romeo” all the way from New York to California for the organization’s recent annual conference.

DR. DONALD BERWICK: When I saw “Charlie Victor Romeo,” I recognized in the stress, and the patterns of interaction, and the kind of difficulties that arise in the airplane cockpit, exact replicas of what happens under not just intense environments, all environments in healthcare– operating rooms, emergency rooms– and they lead to the same kinds of problems that we saw in the play.

SUSAN DENTZER: Perhaps few people understand that more than Dr. Jim Espinosa. He directs the emergency room at Overlook Hospital in Summit, New Jersey, one of four hospitals in the Atlantic health system.

DOCTOR: We probably need to draw some bloods here.

SUSAN DENTZER: Espinosa and his colleagues reenact actual events in health care to try to learn what went wrong. We visited them at Overlook recently as they performed several reenactments related to scenes from “Charlie Victor Romeo.” One was inspired by this scene, based on the 1996 crash of an Aeroperu jetliner after takeoff from Lima, Peru.

ACTOR: Let’s go to basic instruments. Everything’s gone to shit.

ACTRESS: Lima tower, Aeroperu 603.

SUSAN DENTZER: The scene showed what happened when the pilot and copilot realized that the plane’s instruments were giving them skewed readings. The airline maintenance crew had taped over the instrument sensors while cleaning the plane, and had forgotten to remove the tape.

ACTOR: What would be the real speed?

ACTRESS: This one’s okay, they’re okay, the speed… Airspeed…

ACTOR: Yeah, but with all the power cut down, it can’t be!

SUSAN DENTZER: Frustrated, the pilots argued over what to do, with each one trying to establish control.

ACTOR: Yes, because right now we’re stalling!

ACTOR: We’re not stalling, it’s… It’s fictitious, it’s fictitious

ACTOR: Too low.

ACTOR: Terrain.

ACTOR: Too low.

ACTOR: Terrain.

ACTOR: Too low.

ACTOR: Terrain.

ACTOR: I don’t know that.

SUSAN DENTZER: Back at Overlook, Espinosa and his colleagues discussed the lessons.

HEALTHCARE WORKER: The irony and the tragedy of the event, as I see it, is that had they flown the… Just flown the plane– sort of basic compass and stick and external visual queues– they actually could have gotten through it. But they kept returning to the faulty information they were getting.

SUSAN DENTZER: Then they reenacted an event at the hospital that had raised similar issues: Lack of cooperation, disputes over who was in control, confusion over technology, and failure to keep watch over the patient. The scene began when a team of emergency medical technicians, or EMT’s, brought a heart attack victim to the hospital.

HEALTHCARE WORKER: This gentleman had a sinkable episode in the street.

SUSAN DENTZER: The team needed to transfer the patient from the EMT’s heart monitors to the hospital’s equipment. But that proved impossible, since the technologies were incompatible.

HEALTHCARE WORKER: Does your pacer pack go to ours?

HEALTHCARE WORKER: You’ve got to connect the pacer with…


HEALTHCARE WORKER: Can you get that wire down there?

HEALTHCARE WORKER: Which one? Which color?

HEALTHCARE WORKER: The thin wire. That one there. We should be able to connect it there, if it’s working right.

HEALTHCARE WORKER: But as I said, they don’t interface.

HEALTHCARE WORKER: Oh, you’re right.

SUSAN DENTZER: Since the equipment was incompatible, nurse Laurie Sagaard asked Deborah Timpson, the EMT, to leave behind hers behind for a while.

HEALTHCARE WORKER: Do me a favor. Would you just leave your pack for a couple of minutes?



HEALTHCARE WORKER: Because I need it to go back on the truck.


SUSAN DENTZER: As they haggled, they suddenly noticed the patient had deteriorated.

HEALTHCARE WORKER: Oh, I think he might be in a third-degree block here. I’m looking at my monitor.

HEALTHCARE WORKER: Actually, ours is like…




HEALTHCARE WORKER: Okay, I’m getting a pulse, but it’s very slow.

SUSAN DENTZER: After that near- disaster came another one.

HEALTHCARE WORKER: Let me just put on new pads, okay? Ah!


HEALTHCARE WORKER: We need help in here.

SUSAN DENTZER: In the course of putting new pacer pads on the patient, emergency room technician David Samko got shocked.

HEALTHCARE WORKER: You have any chest pains? Difficulty breathing?

SUSAN DENTZER: The episode could have seriously injured or even killed Samko, but fortunately did not. Later, the team sifted through the lessons. Pat Gabriel, the emergency room nurse manager, started it off.

PAT GABRIEL: I could see how this would happen every day, and my wish is that we could somehow not have spaghetti on the bed. When you look at all those wires and those IV’s, it’s just spaghetti. And the issue of somebody being in charge was very apparent to me. Everybody knew what to do, but no one took… there was no director.

DR. JIM ESPINOSA: As you watched it, it was a lot like the feeling of watching the C.V.R. The pilot and copilot, and the nurse and medic sort of problem- solving sort of in parallel tracks without knowing what each other were thinking.

TONY GAMBINO: I felt concern for the patient and for the safety of the patient. And I also wondered how much of the frustration the patient felt.

SUSAN DENTZER: Joe Roebuck, a trainer for Atlantic Health Systems, summed up.

JOE ROEBUCK: What we learned: There was really nobody focusing on the whole picture. The challenge I would have for you, you know, personally, is… For each of you is talking more in experiences like that, and even sharing your doubts, sharing your confusion.

SUSAN DENTZER: With that, the group turned to a second reenactment, once again inspired by issues raised in a scene from “CVR”

ACTOR: This is United 232. We blew engine number two, and we’ve lost all hydraulics.

SUSAN DENTZER: It was based on what occurred aboard a United Airlines Flight in 1989, when the crew realized that the plane’s hydraulic system and flight controls had failed.

ACTOR: Maybe we can only turn right. We can’t turn left.

ACTOR: United 232, I understand you can only make right turns.

ACTOR: That’s affirmative.

SUSAN DENTZER: At that point, a flight instructor who happened to be onboard as a passenger came into the cockpit to help.

ACTOR: My name’s Al Haynes.

ACTOR: Hi, Al. Denny Fitch.

ACTOR: How do you do, Denny?

ACTOR: I’ll tell you what, Al. We’ll have a beer when all this is done.

SUSAN DENTZER: With the aid of Fitch’s calm and levelheaded guidance, the pilots somehow managed to get the plane to an airport runway.

ACTOR: See, we got the tower in view. It’s right here, 1:00 low, Al, 1:00 low. That’s right, pull the left one back. Pull the left one back.

ACTOR: At the end of the runway it’s just a wide-open field.

ACTOR: Left throttle. Left!

ACTOR: Oh, God!

SUSAN DENTZER: The plane cart wheeled as it was touching down and 110 people were killed. But 185 onboard survived, including the crew.

DR. JIM ESPINOSA: They actually were able to save a lot of lives by having an even-tempered expert come in and from the back, who actually turned out to be a captain and a trainer. I think we’re trying to show how the even-tempered expert’s influence, plus the resources that person can bring to bear, could settle the thing down.

SUSAN DENTZER: So the Overlook group tried to apply similar lessons to avoid a distressing and routine occurrence.

HEALTHCARE WORKER: The “D” word? You want me to say it? Okay.

SUSAN DENTZER: That’s “d” as in diversion. That’s what happens when a hospital emergency room becomes overwhelmed with too many patients. Ambulances bringing new patients to the hospital are turned away and told to go to another hospital in the area. Some critics have charged that diversions at hospitals around the country sometimes put patients’ lives in peril. The Overlook team tried to play out what usually happened in the emergency room to force a diversion.

HEALTHCARE WORKER: This lady has chest pain.

HEALTHCARE WORKER: We’ve been waiting here a long time.

HEALTHCARE WORKER: Move this one into the cast room. Move the cast room out right in the hall, right outside the cast room. Dr. Smith was which line?

HEALTHCARE WORKER: Dr. Smith is on 2234.

HEALTHCARE WORKER: Wait, wait, we have a suicide here.

HEALTHCARE WORKER: Look, I really need to get to Mr. Nelson. What room is he in?

HEALTHCARE WORKER: I really have no place. I have really no place. If you could just wait a little bit, I’ll do the best I can. It’s like moving people around.

HEALTHCARE WORKER: Two seconds, Veronica. Two seconds. Look, he can stay with his parents, or his parents…

HEALTHCARE WORKER: She’s having severe chest pains.

SUSAN DENTZER: As is typical in emergency rooms, the confusion and noise escalated.

HEALTHCARE WORKER: Can you pull that one out? I’ve got a suicide in the waiting room. Veronica…


HEALTHCARE WORKER: Joe has somebody with chest pains.

HEALTHCARE WORKER: All right. I’ve got another tele-admission.

HEALTHCARE WORKER: Can you just cover me? I need that phone call.

SUSAN DENTZER: Suddenly a call came in saying that three victims of a car accident were being brought in.


HEALTHCARE WORKER: I just got a call on the radio. We’re getting three patients from an MVA.

HEALTHCARE WORKER: Oh, my God. All right, let me call Linda, let her know what this is. I’ve got a motor vehicle accident with three coming in. What are my options? Are we going to talk about diversion here?

SUSAN DENTZER: Then, borrowing a leaf from that “CVR” vignette, the calming force arrived in the form of Linda Kusnik. She’s Overlook’s chief nursing officer, and the hospital’s top official in charge of operations.

HEALTHCARE WORKER: At some point, somebody’s got to take control.

HEALTHCARE WORKER: Okay. Give us one second.

HEALTHCARE WORKER: I called. Let us just all relax and we’ll try and figure out what’s going on. Why don’t you give me an idea how many patients do you have?

HEALTHCARE WORKER: A total of 28 signed in.

SUSAN DENTZER: Kusnik called on other departments of the hospital to help move patients more quickly out of the emergency room.

LINDA KUSNIK: Okay, now, I know that we held the recovery room open for you to send your admissions up. So is the problem you’re not getting the bed assignments, or is the problem that you can’t get them there?

WORKER: Both. Yes.

SUSAN DENTZER: As Kusnik took control of the system, the sense of panic subsided, and the diversion threat was called off.

LINDA KUSNIK: You should have a good six or seven patients out of here within a half an hour.

SUSAN DENTZER: The reenactment ended, and once again, the team discussed how to make things work better.

GERI FOWLER: You know, you get to a point… When you get to this, there’s a break-off point, you know. You can manage this and you… You continually expand your bag, you know, but you get to a certain break-off point where it just… The bag breaks. There’s just too many pieces, too many demands, not enough hands, not enough stretchers, not enough room, not enough resources to be able to handle it.

HEALTHCARE WORKER: Okay. Linda, when you came in the room as the chief nursing officer, what’d you experience, and how’d you see it?

LINDA KUSNIK: It looked very familiar. You have a calm unit if the charge nurse is calm, and eventually, though, they become so overloaded that they finally do get caught up into the chaos.


LINDA KUSNIK: And so you kind of have to break the cycle, and that’s what has to happen. It means that you really have to focus on what can I do to bring the tone down in the unit, to make it quieter, to start to relieve the stress that’s there, and that’s resources.

SUSAN DENTZER: Later, Kusnik told us that the reenactments motivated hospital staff to tackle problems, and in ways that other efforts to fix mistakes did not.

LINDA KUSNIK: Previously if we had said we’d like to work on flow, not to go and divert, or we’d like to look at a process improvement, you don’t get anybody to come to your meetings, you know. They say, “oh, geez, I’m overwhelmed, it’s too busy, I worked really hard today.” But they were volunteering today. They see the difference. They see the opportunity. They see solutions.

SUSAN DENTZER: And to Dr. Berwick of the Institute for Healthcare Improvement, these ways of surfacing the problems in healthcare underscore a powerful truth.

DR. DONALD BERWICK: The message we’re trying to bring now is we need to work on a culture also. It’s communication, feelings, teamwork, interactions. That’s where safety lies, not just installing a new computer.

SUSAN DENTZER: The institute now plans to use both “Charlie Victor Romeo” and the Overlook hospital reenactments to help spur changes at other healthcare systems nationwide.