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Briefing and Opinion
October 22, 2004

Stress Factor
What do we know about medical mishaps and what can be done to reduce them? This was the topic of a conference held at the University of Michigan Medical Center which resulted in a book, MEDICAL ERROR, edited by Marilynn Rosenthal and Kathleen Sutcliffe. Below are some of their answers, featuring viewpoints from a variety of experts who examine different kinds of medical error, suggest some of the root causes and offer possible solutions.

Stress Factor

One of the global factors that should be evaluated in considering medical error is the stress inherent in today's medical environment. It is our contention that stress affects performance, which in turn produces mistakes. ... Like the driver of an automobile, the physician is more likely to make a medical mistake when burdened with mental fatigue and environmental stressors. These factors are becoming increasingly important as the pace of modern living accelerates and technological innovation expands. Although it is true that we all face such changes, the consequences are more severe in the medical environment because human lives are so profoundly influenced by medical decision making.

Source: MEDICAL ERROR, edited by Marilynn Rosenthal and Kathleen M. Sutcliffe of the University of Michigan, Chapter 2, How Stress and Burnout Produce Medical Mistakes by Darrell A. Campbell Jr. and Patricia L. Cornett.



A Patient's Vies

It is tempting to regard malpractice suits as the ultimate patient answer to medical mistakes. In many respects this would be unfortunate. There is, after all, a genuine difference between doctors who are drunks, drug addicts, or mentally disturbed (delicately referred to by the profession as impaired physicians) or incompetent (bad doctors) and the 90 to 95 percent of doctors who are well trained and hard working and who sometimes make a mistake due to either human imperfection or badly designed systems. There is also a difference between a good decision poorly executed (accidentally giving a harmful does of a beneficial drug) and a bad decision (prescribing a harmful drug.)

Indeed, most malpractice suits could be avoided by timely disclosure of what went wrong and an apology. By some estimates, as many as 80 percent of malpractice cases are filed because of a break-down in the patient-doctor relationship. (Wu,1999). One cannot help but wonder whether this is due to the belief by too many physicians that their failings are "unavoidable," and the patient's "expectations" are the real difficulty.

Source: MEDICAL ERROR, edited by Marilynn Rosenthal and Kathleen M. Sutcliffe of the University of Michigan, Chapter 5, The Patient's View of Medical Errors by Michael L. Millenson.



Nurses' Code

Finding themselves in physician-dominated hierarchies when care goes awry or their level of dissatisfaction escalates, nurses will exert considerable covert ingenuity to protect patients or express their displeasure. Indirect methods of expression are sought over more directly assertive methods because of the fear of being seen as disloyal. This indirect behavior is reinforced by the views of administrators that open expression of such dissatisfaction is disloyal and disruptive. So nurses learn to maintain a code of silence. This silence undermines interdisciplinary collegiality and interferes with a potential first-line filter for medical mishaps.

Source: MEDICAL ERROR, edited by Marilynn Rosenthal and Kathleen M. Sutcliffe of the University of Michigan, Chapter 4, Nurses and the "Code of Silence" by Beverly Jones.