November 30, 1999
The Health Unit is a partnership with
the Henry J. Kaiser Family Foundation.
SUSAN DENTZER: "To err is human," goes the old saying, and that's a reality that much of U.S. industry adapted to long ago. Take the delivery company Federal Express. Even if Federal Express delivered 99 percent of its packages on time, an error rate of just 1 percent, roughly 8 million packages a year would still arrive late. As a result, FedEx long ago adopted sophisticated computerized order entry and tracking systems. They're part of a company-wide effort to improve performance and eliminate as many mistakes as possible.
FED EX EMPLOYEE: Thank you very much. Have a good day
SUSAN DENTZER: Now a new report from the Institute of Medicine, an arm of the National Academy of Sciences, says America's health care industry has an urgent need to adopt some of these same quality-improvement practices. The report says that's because the error rate in medicine is unacceptably high.
The report cited previous studies suggesting that mistakes in medicine injure as many as one million Americans each year and kill anywhere from 44,000 to 98,000. That makes medical mistakes a leading cause of preventable death that kills more people each year than breast cancer or motor-vehicle accidents. Compiled by a group of leading healthcare experts, the report cited instances of errors throughout the health system. Many involve mistakes in medication. Hospital staff may sometimes administer the wrong dose of a drug. That's what happened in the case of a Boston newspaper reporter killed by an overdose of chemotherapy in 1995. The causes of such mistakes are frequently simple but tragic, such as the inability of a nurse or other aide to read a physician's handwriting.
The Institute's report called for comprehensive changes to improve patient safety. That means overhauling the way work is performed in many medical settings, such as adopting computerized order entry for drug prescribing and lab tests. In busy hospital emergency rooms, the report said, medications should be stored in the diluted forms in which they're administered to patients, rather than full-strength and potentially lethal. The report also called for the creation of controversial new systems to collect information on medical errors in hopes of preventing them. Reporting would be mandatory in the case of mistakes that resulted in serious injuries or deaths, and voluntary in other instances.
|A serious problem|
RAY SUAREZ: For more we're joined by Dr. Lucian Leape, a committee member of the institute that prepared the report. He is an adjunct professor at the Harvard School of Public Health. And Dr. Nancy Dickey, former president of the American Medical Association and past chair of the National Patient Safety Foundation; and Charles Bosk, a professor of sociology at the University of Pennsylvania. He is a senior fellow at the Leonard Davis Institute for Health Economics and author of the book Forgive and Remember: Managing Medical Failure.
Dr. Leape, let's start with you. For the purposes of your report, what was counted as medical error, and what was excluded?
DR. LUCIAN LEAPE: Well, medical errors include all the mistakes that people make, from the trivial miscalculation of a dose of a medication to terrible things like cutting off a wrong leg and sort of everything in between. So we're talking about diagnostic errors, we're talking about errors in communication. We're talking about errors in writing a prescription. We're talking about the whole gamut of errors.
RAY SUAREZ: And given the fact that in real life sometimes we bury our mistakes -- sometimes people work very hard to cover them up -- how did you manage to count them?
DR. LUCIAN LEAPE: Well, different studies have used different methods. Most of the major studies have relied on reviewing information and records. And I think you bring an interesting point up. And that is all of them are not included. So some people think the problem is really even more serious than is indicated by those numbers.
|No human endeavor is perfect|
RAY SUAREZ: Dr. Dickey, that suggestion that we set up a government-managed or government-sponsored mechanism for counting these errors, a place to report these errors, how would that sit with the members of a professional association like the AMA?
DR. NANCY DICKEY: Well, I think we clearly need to have a better database, as Dr. Leape points out, but creating a federal bureaucracy brings problems of its own. In fact, when we look at a perhaps parallel example, which is aviation, where they do have mandatory reporting, they discovered that in order for it to work, they had to have it separate from the regulatory agency. They had to be sure it was non-punitive, so that people would call in near misses as well as problems, and they had to make sure that there was confidentiality. In fact, our government is the insurer for nearly 30 percent of Americans. Perhaps the reporting mechanism needs to be a public-private partnership, and clearly we'd have to answer some of the problems about confidentiality and non-punitiveness in order to make it work.
RAY SUAREZ: Well, if you were going to use that aviation model, and use that confidentiality, in effect you'd have doctors telling the government about things they did without telling their patients.
DR. NANCY DICKEY: Well, clearly we recommend to physicians that they sit down and talk to patients when there's been an error or a bad outcome, but I think we're talking about two separate pieces of the same puzzle, if you will. One has to do with trying to identify what causes an error so that you can change systems, change processes so that same error doesn't occur again. The other has to do with the trust that patients have that their doctor does the right thing and when something unexpected or unintended happens, communicates that to the patient and sets about trying to make it right or as right as one can at that point.
RAY SUAREZ: Professor Bosk, any physician is going to say, "What's our position on errors? We're against them." But as an ethicist, how would you enter cost into the conversation, so that we could have sort of an adult conversation about where it comes in?
CHARLES BOSK: Well, I think that's right. I think no one would be in favor of medical errors, and I think the report itself -- or what I've seen of the executive summary -- makes for terrifying reading in the sense that some of those errors seem random, and they could happen to anyone. What I worry about is that putting in place systems, and that certainly makes sense to me -- but doing that at a time when the rest of -- where we're cutting costs and the rest of the delivery system -- so how do we balance the systems that we put into place with cost reduction, with major emphasis on controlling costs and medical care more generally, with less manpower in hospital systems -- I don't think that the systems that the report talks about are frictionless or costless. And the question is: If systems are going to have as much less personnel in hospitals as they are, then how is this work going to be piggybacked onto already overworked workers?
|Balancing cost and safety|
RAY SUAREZ: Or conversely, do we have to concede that a certain amount of error is inevitable and that rooting it out would be so costly that we just can't walk down that road.
CHARLES BOSK: Well, one of the problems for me is that we all understandably want medical care to be perfect, but I think we should recognize as well that no human endeavor is perfect, and what we haven't asked is what's optimal -- just how efficient can we expect an error-ridden, difficult, cognitively complex, manually complex, interdependent system like health care to be? And to the degree that some of those mistakes come from faulty miscommunication, I suspect that those errors may increase as we attempt to control costs. And while the goals of the report are laudable, and while everyone would be in favor of reducing error, I think we do need to raise the question of what are we willing to pay to do that, and what level of imperfection are we willing to tolerate?
RAY SUAREZ: Well, Dr. Leape, why don't you take it from there.
DR. LUCIAN LEAPE: Well, I think Dr. Bosk raises important questions. When we've studied it, we found that error reduction activities usually pay. People tend to underestimate how costly mistakes are. One of the reasons is that many of those costs are hidden. Patients bear the cost. We know, for example, that a serious, adverse drug event in a teaching hospital costs over $4,000. Now, that same hospital, in which that study was done, put in a computerized physician order system that cost several million dollars to develop, and yet by reducing the adverse drug effects by over 50 percent, they recouped that money in less than two years.
So I think there's no question that some safety measures are going to cost money. But many of them will save money, and many of them would cost very little. For example, we know that every year a few patients are accidentally injured because they are injected with concentrated potassium chloride. The nurse thinks it's a different medication. That substance, potassium chloride, doesn't need to be available on the floor where the nurse can pick it up by mistake. Simply removing that substance from the nursing unit eliminates that particular hazard, and that doesn't cost anything. So there are a lot of things we can do -- what we call the low-hanging fruit -- the easy things that would make things a lot safer. But I would submit that some of them are going to cost money, and if we want safe care, we're going to have to pay for that. And I think most people would be willing to pay more to have it safer.
RAY SUAREZ: Dr. Dickey, I know real medicine isn't like the medicine that's practiced on TV, but there is a lot of care that's carried on under conditions of fatigue, stress, pressure to make quick decisions. Aren't all these things factors that make mistakes more likely in any work setting?
DR. NANCY DICKEY: Certainly I think if someone is in a position that they are over-fatigued or overstressed, but clearly we can't always plan medicine to occur at 8:00 a.m. when everybody is fresh on their tour of duty. So we've got to find the right mix of being able to make decisions, even when there's an unexpected crisis, but not allowing the stressors to be too great.
We've begun to address that, by the way, through regulations about how many hours residents in their training years can work at a stretch, and the increased number of physician available in the work force today allows physicians to work much more predictable hours with hours of rest in between their periods of being on duty. Both of those are good for patients, but we'll never probably get to the point that every time a physician is called or is the most appropriate person to respond to an emergency, he or she has just come off of a break period. And so part of training and part of performance is being able to perform in an urgent or stressful or emergency situation.
RAY SUAREZ: A lot of the examples that were given in the report had to do with things as almost silly as bad handwriting. How do you get around that kind of thing, Dr. Dickey?
DR. NANCY DICKEY: I think Dr. Leape mentioned it. We have reasonably good evidence today that both removing the number of steps, how many people have to touch a piece of paper or an order that's being given, and changing to a computerized system, where what is put on the piece of paper is clear and easy to read, will reduce a great many of those mistakes. We're finding, a lot of doctor's offices, hospitals and other facilities are moving towards an electronic medical record. But it does bring us into Dr. Bosk's issues, because those systems are expensive.
If I have to make a choice in my office between purchasing the hardware and software to have a computerized medical record versus hiring another nurse so that patients are seen in a more timely and friendly fashion, how do I make the choice? And if I'm a big hospital, we're not talking one computer, one nurse, here we're talking millions of dollars per system, and I think we have to have more evidence along Dr. Leape's line that says this is going to be cost-effective before we convince hospitals, large clinics, even insurance companies that this is something they ought to pay for.
RAY SUAREZ: Well, Professor Bosk, what should the people looking at those million-dollar decisions be keeping in mind at the time they have to make them?
CHARLES BOSK: Well, I think we ought to start with Dr. Leape's point, which is to get the low-hanging fruit first. That certainly makes a lot of sense. And then I think the folks that are making those decisions are really caught between the demand of employers buying health insurance to keep those costs as reasonable as possible, and then at the same time, the contradictory demand that care be as perfect as possible. And I don't think yet we as a society have a good handle on how the balance those two needs. We want both, and it's very hard to have a serious discussion of how to balance those two needs together.
RAY SUAREZ: Well, Dr. Leape, as we wrap up, maybe we could talk about what happens now. I'm sure you don't want this thing collecting dust on a shelf somewhere.
DR. LUCIAN LEAPE: Not at all. And I think one of the exciting things is that the Institute of Medicine has come out and made specific recommendations about what should be done: Recommendations for health care organizations to implement some of the known safety practices, recommendations for a center for patient safety that will collect information and sponsor research, and a number of other recommendations that we hope will be picked up and acted on. I think what we've got is some momentum here. The AMA two years ago founded the National Patient Safety Foundation, which has greatly raised the awareness in the medical community. Now what we see is the Institute of Medicine saying let's move on with this. It's time to take action and not just talk about it.
RAY SUAREZ: Doctors, professor, thank you all.