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Dr. Wachter and Dr. Leape on Medical Errors

In 1999, a study of medical errors found that the number of people killed by mistakes in care equaled one jumbo jet full of passengers crashing every day. Two of the researchers that uncovered these statistics, Dr. Robert Wachter and Dr. Lucian Leape, discuss how things have changed since their report.

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    It's been five years almost now since the Institute of Medicine came out with the errors report. I'd like to ask both of you, but I'll start with you, Lucian, since you spoke to us back then. What's changed in five years? Is patient safety improved? Are patients any safer now than they were when that report came out in November of 1999?


    Well, a lot's changed. We're safer. We're not a whole lot safer, but I think there's no question that we put in a lot of changes that are making a difference. But the main thing that's changed is that people no longer are questioning whether we can or should do this.

    I think you could say that 10 years ago it was inconceivable we would do anything about this. At the time the IOM [Institutes of Medicine] report came out, it still seemed rather improbable, and I think now it's inevitable that we are going to make the changes we need to do for safety because people no longer question whether it's possible. They don't questions – they no longer question the numbers.

    When the island report came out and said 44-98,000 had died every year from preventable injuries, many people said oh, that can't be true. Well, you don't hear that anymore. We realize that we've got a big problem and we've got to move beyond it.

    So I think we now have accepted that. People now realize what the [report] said was that we need to change our systems, and people are working at that. So I think we've – we've changed the conversation, we've changed the whole mood about what we're doing and that's got to be positive.


    Bob, what do you think? Is the system safer? Are patients safer?


    I think we're a little bit safer than we were back then. The data are not very good to help us answer that question, but I remember back in the original report, the analogy was made that the equivalent of a jumbo jet going down every day was how many people died of medical – medic mistakes. And my own estimation is we're probably down to a [Boeing] 727. That represents progress. That's a lot of lives saved from what we've done, but it's still completely unacceptable.


    Many of the recommendations in the report had to do with changes that should be undertaken in terms of collection of data, systems, etc. Let's just talk about a couple of the more noteworthy ones that haven't materialized. For example, there was a suggestion that a national mandatory error reporting database be created so that we could begin to capture what was happening in the field of medical error solution. That hasn't happened. Why hasn't that happened, and what's been the effect on safety of the fact that that hasn't occurred?


    There's a tremendous resistance to that by the medical establishment. Hospitals and doctors really were opposed to that because they felt it would put them in increased risk of being sued. They were concerned about the liability risk. And so that really didn't get very far at the national level. But interestingly enough, another five or six states have put in mandatory reporting systems since then.

    Reporting has always been a state-wide activity, not a national activity, and what [was] recommended was merely that that be coordinated and that the data be accumulated. But they did not recommend that we set up a federal reporting system.

    So what we have seen is some expansion of the statewide reporting system, but with an interesting twist and that is what many of them – what most of them have done is made the information confidential. And so that attempts to address the issue of risk – liability risk and shame that goes with reporting.

    And so we're seeing some increase in reporting, but I think in a safer fashion which makes it more palatable.




    Well, I think we have seen some more reporting. I'm actually not a big fan of reporting. Reporting was one of the aviation analogies from around the time of the original IOM report. The Aviation Safety Reporting System is very robust and really very helpful. A lot of – whenever there is a near miss, you don't need a reporting system for an aviation accident. But a near miss gets reported, and useful action comes from those reports. They get 30 or 40 thousand reports a year, and it's been very, very helpful that way.

    The health care analogy doesn't work very well in terms of reporting, and what we've seen with some of these state reporting systems is they get — some of them have gotten 100,000 reports, and they're sitting mostly accumulating dust on shelves or in computer databases. In some ways this is part of the problem. There are so many errors, there are so many near misses in health care, that reporting them up to the state or to the federal government, nobody has really quite figured out how to take those reports and do something useful with them.

    Where I think we have made some progress in reporting is that individual hospitals have something called incident reporting systems, and in good ones, my hospital has a good one where it's a computerized system when a nurse or a doctor sees something that went wrong, they report it through that system. And there is then a feedback loop. Action occurs.

    If I'm chief of the medical service in my hospital, I will get an e-mail about that this went wrong on my floor, and so will the head of nursing. And we now have the information, we're motivated to do something about it, and we can see patterns.

    So I think this may be more local baseball, and the inclination that everybody had that a national system or even a state system would be the right way to go. I think the jury is still out as to whether or not that really is going to make a difference.


    I'd like to second what Bob says. I'm not a great fan of national reporting either. But I do think the important thing is not reporting, but what happens when reports come in, and I'm fond of saying we need a national response system instead of a national reporting system. We're not going to get it at national level, but we are seeing it at another level and that is within systems.

    The Veterans Administration health system has got a system reporting system, and also within specialties. The intensive care unit specialist, for example, set up their own reporting system, and the purpose there is to learn from each other's mistakes, and it seems to me that's what we can – that's the benefit of reporting. And that's happening on its own without the government participation, without any external funding.


    Well, speaking of government participation, there was a lot of call for federal legislation either to set up these kinds of systems – reporting systems, or undertake other changes, and that hasn't materialized either. How big a failure has that been?


    Well, I think it's a giant failure. The Institute of Medicine report in 1999 called for a national commitment. For most of us, that meant that the federal government would say this is important. We're going to put our money behind it and really make it a national effort. Some of the – what we need is a moon shot. I mean, a serious national effort to reduce medical errors.

    We said we could reduce medical errors by 50 percent in five years if we had that kind of national commitment. That never materialized. What the government – what Congress did do, which I think was very useful and very important, was to appropriate $50 million for research in patient safety. They did establish a center for quality and safety within the agency for health research and quality, but that's about all they were able to do.

    So simply beyond reporting, the call was to have a – the approach has been to pass legislation to provide protection against discovery for information that is shared across state lines. The Joint Commission for Accreditation of Health Care Organizations, for example, requires hospitals to report serious events to them. But the hospital lawyers tell them when they do that they expose themselves to the risk of a malpractice suit.

    Well, the Joint Commission is not interested in increasing the risk of malpractice suits, but it wants to learn from those. It wants to – these are serious events where there's been a root cause analysis, where the hospital has really tried to understand what went wrong, to find out where the problems were and to do something about it.

    So these are the kind of events that we can learn from. And so that information ought to be accumulated and ought to be shared broadly, which is what the Joint Commission tries to do. But they can't get hospitals to report as long as they're at risk of being sued. And so there's been a bill before Congress every year for the last four years to provide protection, and we just don't seem to be able to get it passed. And so I think that's too bad. I think it would improve – it would improve reporting. But the more serious failure is we haven't really put any significant amount of money behind this. We should be spending much more on safety research than we are.




    It's both safety research and implementation, and I completely agree that when the IOM report came out, there was hue and cry from everybody. I mean, just think about if a jumbo jet was crashing every day what we would be doing to solve that problem. Even if it's not a jumbo jet but a 727 or a Greyhound Bus going over a guardrail everyday, what we would be doing.

    Well, what we did was put $50 or $60 million dollars into the federal agency charged with trying to fix this. That was very, very helpful because that was 50 or 60 million that was zero a year before that. So it was terrific.

    But one of the things that really has struck, I think, all of us over the years is that this is to some extent a disease of medical progress. As medicine gets better and better, it also gets much more complex.

    You have more specialists and more technology, and we didn't have MRI scanners 20 years ago and now we have MRI scanners. They are terrific but also periodically oxygen tanks will go flying through the air into them. The drugs are more toxic even as they're better.

    The federal budget for the National Institutes of Health, which is really what we spent on progress, is $27 billion dollars a year. So there's a 500-fold difference between what we spent on progress, which is all great stuff but it actually makes the system less safe because it's more complex, and what we're spending on safety. It's just not enough to do the job, and not commensurate with the threat to real people.


    Let's talk about what has happened at the Agency for Health Research and Quality, as it is now named, and specifically the site that was created to allow people to report errors. And Bob, you are the editor of that site. What do you see as health professionals and others around the country weigh in on what errors have occurred in their systems?


    Well, the site, which is called Web M&M, is what essentially a reporting system if you think about it. It is a site through which providers – doctors, nurses, others – can anonymously report cases of errors. And where I think it differs from these other reporting systems that gather 100,000 reports, we take the five most interesting ones and illustrative ones and we post them every month with expert commentaries, including Lucian has commented on one of the cases on the site.

    We have found that to be immensely useful in people beginning to understand the true nature of medical mistakes. I think one of the key paradigm shifts here, and Lucian really was the father of this for the field, was that this is not really about bad doctors and bad nurses. You know, I go up to friends or family and ask them about medical mistakes, and they will all have – they'll have anecdotes about medical mistakes, and there just cannot be that many dumb or careless doctors or nurses. And through the site I think it has been a way of educating patients, doctors, nurses, administrators about the true nature of medical mistakes.

    A typical case, last month we posted a case of a patient who was supposed to get a cardiac monitor – that's called a holter – and was given a piece of paper that said holter on it, and went to a clinic and gave it to a nurse, and ended up getting allergy testing because he had gone to the allergy clinic, and the note that accompanied him back to the hospital was we did allergy testing, which is 30 pin pricks on your back, on Mr. Holter.

    Now, it's funny. Luckily, no terrible harm came from it, and you might say that was really careless, but that really is a system problem. You could envision a system where that sort of error, which is really just basic procedures and redundancies, couldn't happen.

    And I think that's the value of that kind of site, is educating people about the true nature of errors. And people are desperate for solutions. Everybody – every doctor, everybody – every nurse, every hospital administrator knows we have a terrible problem, and they really are desperate. And really only over the past five years they've become desperate to say all right, what should we do now. And the site, one of the things that's been nice about it is we not only tell the stories and do it in a dramatic way, but we also give people solutions.


    I think the agency also has been very central to raising awareness and also raising expertise. In addition to this site, in addition to supervising the great expansion in funding and research in patient safety, they've convened multiple conferences on specific safety issues. They set up a training program for patient safety officers and for the states in conjunction with the Veterans Administration, and they have really been a voice and a center focus for safety, which is exactly what the Institute of Medicine had in mind.

    So I think that part of our government has done a great job. I really do. They, together with the National Quality Forum, which is an entirely private organization, which has done a fantastic job of setting standards, of coming out with a list of the types of events that should be reported when things go wrong, of coming out with what's now the definitive list of safe practices that the Joint Commission is now getting hospitals to implement.

    So we've had some impressive activity at the national level, even outside the government. So I think we've had – we've really enlisted a lot of people in the safety cause since the IOM report came out.


    Let me say one more thing about – by virtue of our Web site, by virtue of some of the work that ARC has done, in our book where we talk about dramatic cases, medical errors, we've begun to lift the veil on all of this, and one of the most surprising to some extent — but I guess it shouldn't have been – comments that I've gotten about the cases on the Web site, the cases that we have in the book, many of which are really dramatic and flabbergasting, everybody says oh, yes, we've seen this at our hospital, we saw that at that hospital, and these are the best hospitals in the country and they come up and they say oh, yeah, we had that when we had that.

    I don't think any of us knew how generalizable this was and how much it was happening everywhere. There was so much shame associated with it. There were no venues where we could talk to each other, or had a language to talk to each other about it. And then you began to realize that it's not simply that we have – we don't have a good hospital or people aren't being careful enough. These are absolutely sort of generic problems that happening everywhere, and that really gives you the sense that this really is a systems problem. As we make the system safer, we will – we will be able to stamp these out.


    One interesting question is that if you think back in the last five years, there have been a couple of spectacular medical error stories, but really only a couple that made it out into the public realm, the Jessica Santillan case probably being the most visible of them. Is that because people want to talk more about this, or the opposite effect? I mean, judging from the numbers, we know that thousands and thousands of errors took place, and probably many more patients died. What explains the fact that we really haven't seen some spectacular errors cases much in the last five years?


    It's a very interesting phenomenon. We read about this in the book about what it is that makes a spectacular error newsworthy and makes it above the fold, or makes it onto NewsHour. And to me, it seems like a sort of random process because I know for every patient like Jessica who got the heart/lung transplant of the wrong blood type, I know of a lot of other institutions that said, "We had that happen and the media just didn't happen to get it." And there's almost any error you can mention, that will be – that will be the case.

    So it's not entirely clear to me what it is that's the filter that allows the one case a year to make it through. I know how terrible it feels to be – first of all, obviously, the biggest tragedy is to the patient and the family, but even to be at that institution – that happened to be at Duke, a terrific, terrific hospital where that happened, and you feel like, you know, why did they happen to get me in the cross-hairs, and yet it is because of that case and cases like it that people get the dimensions, the drama. They sort of feel what this is about, and it's hard to figure out how you would do that in a more sort of systematic or conservative way.

    It's a little bit unfair to teaching hospitals in the Northeast, which is, I think, where the media tends to be centered, and where when you look at the cases that have made it into the media fast lane, it's a very disproportionate sample that often is, if you think about it at Harvard and Duke and Johns Hopkins, it's very difficult for anybody to argue that these are not spectacularly good hospitals, and that's somewhat unfair that those hospitals happen to be in the limelight in media markets that happen to catch the errors.

    I think the errors are much, much more ubiquitous than that, and it just happens to be that those are the ones that filter through.


    The interesting question is why do some hospitals take a tragedy like that and use it as an opportunity to totally reinvent themselves, which is exactly what happened to Dana Farber Cancer Institute. It totally transformed itself.

    They would be the first to say they're not perfect, but they have really created a culture of safety that's quite unique. I think Johns Hopkins has responded in a very positive way, made some very dramatic changes, whereas so many hospitals don't change. And as Bob says, it's not just the ones we hear about. Every hospital has had a terrible event, and the question is why isn't that enough to get them to make the changes as well, and we don't have any answer for that.


    We mentioned briefly the role of the joint commission in engendering some changes. Let's talk, and starting with you, Bob, of some of the things the Joint Commission has propelled the system – JCO has forced some changes.


    Well, I think the Joint Commission is the main regulator of health care quality and safety, and I think they've done a terrific job in the last five years. I think you could argue that it is low hanging fruit, but it's fruit nonetheless, and until they came along and forced us to do some of the basic procedural elements of safety, we weren't doing them.

    My two favorite examples are these: I call my favorite Chinese restaurant in San Francisco and I order their special eggplant and their hot and sour soup, and before I hang up the phone, they inevitably say, "Let me read your order back to you," as if it would be a tragedy if they gave me the wonton. And yet until JCO forced us to do it, I could call the nurse's station of any hospital in this country and say, "I'm a doctor, and I want to give Mrs. Jones" – and I could name a medicine which could kill her if given incorrectly, and they would say, "Thank you, Doctor," and hang up the phone. JACO now has forced us to do that simple safety step, which is called a read-back. The restaurants learned it a long time ago. We never did.

    The second example is something called sign your site, which is now familiar, I think, to most people, the idea that surgeons now initial the surgical sites to make sure they don't cut off the wrong leg, or operate on the wrong body part. Well, before JCO came along and regulated the way that needed to be done, orthopedic surgeons figured out this was a bad thing to operate on the wrong body part. And so some of them began on their own marking the site.

    Unfortunately, some of them put an X on the spot that they wanted to operate on, as in X marks the spot, and others, equally well meaning, put an X on the leg that they didn't want to operate on, as in don't operate here, and you had more chaos.

    So there is a really important role for regulation here. It's not everything. It can't – you can't regulate culture. But JCO stepped into that breech and said here are some basic things that everybody should be doing the same way, and I think they provided a vital service, and much of the progress in safety, I think, has come from those simple steps.

    The big question I think we've been grappling with is now what? Once you have that low hanging fruit out of the way, what do you do as things get a little bit more difficult, as you start dealing with culture, and that regulation is not going to be the complete answer there.


    And just to finish, what does JCO now require in terms of signing your site?


    Well, they now require that surgeons put their initials on the site, and there's a fairly elaborate process involved –


    With the patient involved.


    — with the patient involved, exactly. With the patient there. And there's a fairly elaborate process to insure that the patient is there, to insure that it's the right patient, the right surgeon, and they go on – and the right body part – and they go on to something called the time out. And a time out basically is before the surgeon puts in the first incision, the whole team gathers together – the surgeon, the nurses, the anesthesiologists gather together and essentially have a huddle and say let's stop before we do anything and let's be sure we all agree who this patient is, what part we mean to be operating on, what the surgical technique is going to be about, and that's engendered not just a little bit more safety as it comes to operating on the right body part, but when you talk to surgeons and nurses, and I've talked to nurses and they said, "It's the first time I've actually had a real conversation with the surgeon about what we were doing."

    So it's actually a very nice mechanism not only to operate on the right body part, to engender the level of teamwork that I think is critically important.

    As we talk about culture, though, there were a lot of surgeons, and there probably still are, who say, "What is this – what is this thing about? You know, I've never cut off the wrong leg. Why do I have to – am I supposed to hug the nurse and sing Kumbaya." You know, that's kind of crazy.

    So we had to work through the cultural aspects of surgeons recognizing that nobody came into work that morning expecting to cut off the wrong body part. The only way to prevent this is come up with a standard procedure, involve all the members of the team, that they're all doing and thinking the same thing, and I think it's been very successful.


    This is a good example, though, to answer your first question, Susan, which is what's the evidence that care is any safer. We don't have any data to show that there are fewer wrong legs being taken off. We don't have any data to prove that patients are getting the right operation more than they used to. But there's no question that these kind of things are making a difference because hospitals – now all hospitals throughout the country have to do this.

    And so the payoff for a lot of this may be a little slow in coming, but that's why I feel quite confident in saying I'm sure care is safer now. It's just not that – we don't have numbers to put on it. But this is a see change, to create an atmosphere in the operating room that is like a team – that is a team in every sense is a major change, and I think we're going to see a lot more of that sort of thing happening, and that's got to be good.


    Let's stay for a moment on these cultural issues because as you said a moment ago, Bob, we need to take this to the next level, get beyond the low hanging fruit. What kinds of things will help engender more progress in patient safety on the cultural realm as much as anything else?


    Well, I think some of it is already happening because it's the – it is the sum of everything that's going on. You know, when – a nurse always asks the patient his or her name before delivering a medicine. That puts in their mind the idea that they're doing that for safety, the time out, those sort of things. I think the culture is changing slowly, but I think what we have recognized is the culture is sticky. It forms in a certain way and tends to stay that way, and you can't wish it away. You can't say let's change the culture and it just changes. And there have been a number of places now that have begun to do specific training, teamwork training to try to shift the culture, and the early evidence from those experiments is very positive.

    Here is an area where the aviation analogy really, I think, is quite powerful. Thirty, forty, fifty years ago in aviation, you had – you didn't have people working together as teams. You had swashbuckling top-gun pilots who worked as rugged individualists and didn't really think about their role as being members of teams.

    You had a very steep hierarchy, and then it changed. And it didn't change because anybody said – willed it to change. It changed because there were a number of terrible, terrible aviation accidents, including the collision of two 747's in the Canary Islands in '77 that ostensibly were about poor teamwork. There were people in the cockpit who suspected that there was another 747 in the way, but the boss, the pilot said, "I'm sure it's out of the way." It was a foggy morning, and he took off and flew into another 747. It was only after that that aviation said we have to train away those sort of hierarchies.

    Now, their stake is a little bit more personal than ours. When a pilot makes a terrible error, he dies at the same time as the 250 people behind him. And so for us it's been a little bit harder without the same skin in the game, I think, a little bit harder to generate the passion for that sort of change.

    But there now are very good examples of institutions where they're doing a ton of teamwork training, the docs and the nurses and the pharmacists and the clerks getting together and working through simulators, or working through scenarios, and learning the consequences of that kind of hierarchy. And it's not going to change overnight but we're beginning to see it changing, and I'm beginning to see among medical and nursing students kind of a different thinking about what their job is.

    Their job is going to – in large part it's not just going to be about how brilliant the doctor is anymore. It's going to be about how well does this team function together as a unit, and that's going to take a very different kind of doctor, a different kind of nurse who needs to be a little bit more assertive, everybody learning to work together on behalf of the patients, and I think it's starting to change.


    Lucian, what's your perspective on how these cultural issues have changed, and need to change further?


    Well, I think you need to go back because the mental image of the physician, the Marcus Welby image that we all grew up with, and which we lived with for a century was that a hospital was a place where a physician brought his or her patients to take care of, and everybody there's job was to help the doctor take care of the patients. And so we have developed a very strong culture of physician autonomy, a hierarchical system where the nurse's job is to say yes sir – it usually was a sir in the old days, and the whole system was oriented around meeting the physician's desires. And so physicians became the kind of people who expected everybody to cater to their whims.

    So we're talking about a see change in culture here. We're talking about a totally different way of thinking about not just what people do, but how they interact with one another. So it's not surprising that it goes slow. It's not surprising that their surgeon will walk in and say what's this all about.

    I think the fact that it's happening at all is rather remarkable when you look back at what a very major change this is. It's a change we have to make because modern medicine is a team sport. I mean, modern medicine consists of multiple people bringing to the patient their different expertise. The physician is always going to be the key person in that because he or she is the person that makes the diagnosis and prescribes the treatment. But no doctor provides the treatment. The doctor provides only a small part of it.

    So recognizing that and changing that is a huge task. This is a bigger culture change than anything anybody has ever gone through before. So we're – we're sort of feeling our way, and it's not surprising that it's – that it's not going smoothly. But I'm with Bob. I think – I think teamwork is an idea whose time has come. I really think five years from now there won't be any question about the timeouts, the briefings, and working together.

    And as with aviation, I expect it to make a big difference in safety. But let's not underestimate the magnitude of the change we're asking people to take – undertake. A lot of doctors are concerned about losing their autonomy, about having people tell them how to practice, and what we're saying is we're not really telling you how to practice, we're talking about how to enable you to practice the way you want to practice, but more effectively. I think that idea is catching on.


    I think there's an interesting example – I'm working now with a group of pilots who are doing some of this training in health care, and they went into the OR's of a major hospital several months ago and I asked them what was their impression, and they had several impressions.

    They said first of all they were just amazed how bright people were, how committed people are, the quality of the technology is all very impressive. But the most impressive thing that they took away from it was they asked the nurses how do you set up the OR for this kind of surgery, or how do you – what's the process of getting informed consent from a patient. And the answer was well, for Dr. Leape – well, probably not Dr. Leape, but for Dr. Jones we do it this way, and for Dr. Smith we, of course, do it this other way because he prefers it that other way.

    Now, in a way you can't blame Dr. Jones or Dr. Smith for that. They have preferences about the way they like things set up, and we never recognize the consequences of that sort of customization.

    The pilots say, "I go into a 767, a cockpit, it looks the same. It doesn't matter which one I go in, it always looks the same. We have a standard language that we use to communicate with each other. Why? Because it's far safer if we have that."

    And so it is a big cultural change because the doctors have always been given the right and the opportunity to articulate I like it done this way because of my personal preferences or foibles, and we're going to say to them, "Oh behalf of the patient's safety, we can't allow that anymore. All of you have to get together and agree on the one best way of doing it, and then we're going to do it that way because that will be – that will be far safer."

    It actually will also be far more efficient and save a few bucks, and that's good, too. And that just takes a little bit of time and energy working through why it's so important in getting people to – to then agree on the one standard way of doing it. But I think we are starting to make some progress.


    At the time of the report, this was heralded as one important set of changes that need to take place. There obviously has been a lot of advancement in the IT realm over five years. What has it accomplished, Bob? What good has it done, and as we contemplate things like a greater move to electronic medical record, among other things, what is the potential for even greater safety?


    Well, it's very clear that part of the answer may be – maybe most of the answer as it will turn out over time, will be in better information systems, in essence where an information intensive business with very high stakes. What we've seen is both the promise and the challenge.

    The promise in a small number of institutions that have really done this and done it well, and they've mostly been working at it for 10 or 15 years, but when you go into those institutions and you realize how incredibly powerful it is to not have to remember what drugs interact with each other, or whether the patient is allergic to a certain medicine, it's hard-wired into the system. It's really very powerful. Many institutions now have all their X-rays online. There's no more film running around. I don't have to go around and find the film. It's always – on an X-ray it's always on the computer. That's really very powerful.

    What we've also learned is a couple of other lessons, though. One is it does not fix the whole medical errors problem, and I'm seeing a few institutions where you talk to the board or the CEO and they say yes, we've invested in patient safety. We have – here's our IT budget, and that's their entire patient safety budget.

    It doesn't solve all the cultural problems and all the kind of basic procedural problems. It's a part of the puzzle.

    The second thing we're seeing is places that are now buying IT systems off the shelf and air lifting them in, and turning on a switch and saying isn't everything fixed. And it turns out just to be a little harder than that. And there's a stumbling around phase that some institutions are going through.

    That said, there's now a federal coordinator of IT efforts. I think that's incredibly important. David Breller, and he's exceptionally good. There is funding now to do some IT research.

    I think we're moving in the right direction. I think the tipping point here will be when it will be inconceivable for a hospital to go out and say we're a great hospital, and then a patient comes in and sees the doctor still writing their chicken scratch. And I think we're almost there. I think the patient who goes online to make their plane reservations or their restaurant reservations will increasingly find it's just weird that they go into a hospital and the doctors are still writing. And when we hit that point that hospitals just can't get away with that anymore, I think that's when we will have tipped and then every place will go ahead and do it, and I think that will be a great day for patient safety.


    The question is how do we make it happen. And the problem is not just the complexity of the hardware and how you get used to using it and so forth, but there's a very major upfront cost. We would like to have every physician in his or her office have a computerized patient record for every patient.

    By getting that to happen requires not only that they buy the equipment, the computer and software, and we all do that, so that's not a major expense. But they have to learn how to use it, they have to take time out from their practice to do that, they have to pay for putting in all the patient records, entering the data in the system. It turns out to be somewhere in the range of $50 maybe $100,000 for a practice to computerize. And physicians have been unwilling to come up with that kind of money up front because they have no way of passing it on. That's a pure expense which is not insignificant.

    So the question is who's going to pay for that. If you look at the bill for the country as a whole, it's probably in the range of $2 or $3 hundred billion dollars, and I don't – none of us think the government is going to pay for that either. It did in England. In England, doctors – family practitioners have computerized patient records in their office, but the government bought it for them.

    The government bought it for the Veterans Administration. They have computerized patient records in the Veteran's Administration for 10 years. But none of us think the government is going to buy it for all of the doctors in America. So the question is who is going to pay for it, and the answer probably is the insurance companies, which doesn't mean you're going to pay for it because the evidence is that for every dollar spent in implementing – developing and implementing a computerized patient record system in a doctor's office or in a hospital, the insurance company will benefit probably to the tune of $2 or $3 back over a period of five years.

    So they can – they can commit several million dollars or a hundred million dollars over a period of a year or two and get back four or five hundred million within several years because they will have – – there will be fewer patients that receive inappropriate treatments, there will be fewer medical errors, and therefore they won't have to pay for the adverse events. It will be much more efficient billing because the information will all be delivered electronically.

    So in terms of the benefit, clearly the patient's benefit in terms of safety, with computerized patient records are going to make for patient's safer care. The doctors are going to benefit because it's more efficient, but the financial benefit is going to come to the payers and therefore, it's reasonable for them to pay for it.

    Some of them are beginning to realize that, and I think we're going to see over the next few years that the payers get into the mix and say it's time to do this, we'll put up the money. Now let's get on with it. And that's why I'm very optimistic. I think we'll have – I think we'll have computerized patient records throughout the country in the next five years.


    You showed five years ago a famous picture which was a prescription written by a physician, and the handwriting was completely illegible. It wasn't clear whether the person had written his name, a medication, what-have-you. Is that still with us?


    Only about 95 percent of prescriptions are written that way. Exactly. You know, that's why – you know, some people say to me, "Well, you know, the computerized [data] entry, you know, that is so complicated and expensive," and I say, "You don't really think it's better to write it on paper, do you?" Of course not. And so it's a matter of how we get there. But unfortunately, that's still the norm, and that's what's got to go.

    Now, an interim solution, which a lot of doctors are using, is the hand-helds, the little PDAs where they can – they can do it on the – on a computer in their hand, in effect, and we now have even systems where that can be automatically, electronically sent to the pharmacist, so there is no paper. And then the pharmacist also, they have all these – they have computers to check it. And so, in the ideal system, which is working in a lot of places, not only does the physician have the computerized order entry in his hand, but the pharmacist also does a double check and makes sure that the patient is not on another medicine that doesn't interact with it, make sure they're not allergic to it, and all that. And that's got to improve safety. So I think this – I really think this is an idea we're going to be – it's coming and we're going to be in good shape in just a few years.


    I'd just say that this is one of those that is not a two-for, it's a three-for or a four-for, because even if the motivation to get the computers into the hospitals and the doctors' offices was to get rid of my crummy handwriting, which is a very noble goal, once it's there and once it's really working well, all sorts of fantastic things will begin to occur via the computer.

    So, for example, one can envision a world not that far away where a patient gets admitted to me in the hospital, and I type in the diagnosis, that the patient is having a heart attack or pneumonia, and it feeds at me, here is the latest evidence about the best antibiotic to use. And now the doctors will have some play there. Every patient is different, but it will sort of guide you toward the right care.

    Every year now the explosion of medical literature – there are 10,000 or 20,000 new clinical trials coming out every year, so the notion that I think I had during my medical school days that I could just learn all of that is now laughable. And the only way that physicians will be able to synthesize all of the new information and provide the latest and best care to patients is if it somehow is available to them in the process of them caring for patients. It's no longer going to be me running off and finding a book, or remembering that I saw something like that in an article someday. That's really where the breathtaking potential of this comes from, in not only stemming medical mistakes but also improving a level of quality to – to, I think, a level that we haven't even begun to think about.

    The first thing we have to do is get every doctor and every hospital wired, and as Lucian says, the key issue is how do you pay for that? Who is going to bear the cost to do that?


    There's another point that I think that your viewers would be concerned about, and that has to do with privacy. I think a lot of patients are concerned about computerized patient records. As a matter of fact, we've already had a letter to the editor about it in Boston, and we've talked about our plan and people said, "Wait a minute. This is – this is dangerous." And it's very important to dispel that because it is not very difficult technically to encrypt the information and to make sure that access is limited to whoever the patient wants to have the access. The patient can control that.

    Most of us think that patient records ought to be patient records, and that doctors and hospitals ought to have access to them, but that they are fundamentally records that should belong to the patient. And there are technical means for making it possible for patients to determine who will see the records, or to sequester parts of the record.

    The patient may not want you to know that they've – that they have AIDS, for example, and so they can keep that information sequestered.

    What we want, however, is that if you or I find ourselves in an automobile accident in the middle of Montana, that you can go in an emergency room there and the doctor can call up your medical record and find out what medicines you're on, what you're allergic to, and so forth.

    The technology is all there, and we've got to make that happen. But I don't think there's any – I really don't think there's any risk to patient privacy. We can do this safely as well.


    I would go even further than that, which is that you can make it more private with the computerized system than the present system, so you go around a hospital now that it's not computerized, and you see the doctors with index cards that are falling out of their pocket, and pieces of paper that they've left in the cafeteria, it is very hard to guarantee privacy in the chaotic paper base system that we have. And I think there are risks there we've got to be careful about, but in a way I think we'll be able to better guarantee privacy in a well developed computer system.


    One system that has put many of these advances into place is the VA Lucian, put in context for us, where is the VA relative to all the rest of the U.S. Health Care System in terms of tackling this question of patient safety?


    Way ahead. The VA has had a computerized patient record and a computerized patient order entry for quite some time. One of the interesting phenomena is that, as you may know, VA hospitals are by law required to be affiliated with academic medical centers, and one of the consequences of that is the residents in training in all of the specialties – medicine, surgery, and others – rotate through Veterans hospitals. And so what we have now is throughout the country residents who have been in the VA hospitals, and they come back to their hospital and say, "Why don't we have the computerized patient record here like they have in the VA" because that system has been up and running, and working very well.

    The VA has also done some other things that are very important in safety. They've done other high tech fixes. They've put in bar coding for checking of drugs, which other hospitals are beginning to use. But in addition, they have organized their whole structure for accountability, so that when something bad goes wrong in the VA hospital, there is a reporting of it because it's safety reported. They've created an atmosphere where people don't get punished for making mistakes and reporting them. So people report, and then there is an investigation. And then they find out, if they can, what's wrong, and the team makes a recommendation about what should be done.

    That goes to the CEO of the hospital. The CEO is required to either say yes, let's do it, or no, we're not going to do it, and here is why," and that then in turn goes up the channel, all the way up to headquarters.

    So the VA has created accountability at ever level, from the individual to the department chairman, department chairman to the CEO, CEO to the regional director, and – which is another way of saying they're serious about safety. We've got a system to make sure that when things go wrong, we respond to it, and I think it's a wonderful model. It's the kind of thing we need to do in all health care systems, and I think they've really led the way.


    And how much of what they have done has been emulated by private systems in particular?


    Well, I think very few hospitals are as thoroughly integrated and organized as the VA But one system that I know of that we all know about is Kaiser Permanente, and they have had a great deal of interest in adopting these methods. Kaiser is putting in computerized patient records throughout their system. They also are now in the process of doing team training for all of their physicians. And so some of the big systems – Kaiser is one and there are others that are adopting these methods. I think it's no question about it.




    Well, I would amplify both of those, and I think point to something Lucian said, which is these are systems. And I think one of the things that we have learned is that the kind of chaotic and dysfunctional way our health care system is set up on a broad basis doesn't work very well for patient safety. And one of the big elements of that is this very strange organizational dichotomy that we have.

    For historical reasons, there are hospitals – they have CEOs, they have boards, and the hospitals employ a whole lot of health care providers – nurses, pharmacists, clergy, nutritionists, but generally not the doctors.

    The doctors are mostly private practitioners, and most hospitals around the country there are based in the community, they run their own office, they are individual entrepreneurs. And that sort of worked well, or maybe okay in Marcus Welby's day, but these days it doesn't work very well at all when the fundamental aspect of this is how do you get everybody who is important together at the table, figure out where the resources are coming from, and hospitals typically are deeper pockets than the doctors are, and then get them to all agree on a set of goals, agree on a set of things they're going to try to achieve, and work together to achieve them.

    And I don't think it's any coincidence at all that the VA has been proactive here, and not only wanted to do it, but accomplished many things, and Kaiser Permanente is sort of the same kind of – it really is a system. The doctors and the hospitals are aligned in a way that doesn't exist in community – in community settings.

    That's not to say that there aren't terrific examples of progress in community settings, but when you ask those settings how did you do it, the first issue was the herding cats issue, which is how do we get the doctors engaged when the doctors are 100 or 1,000 different doctors scattered around the community, and that's not a trivial task. So we have the system that we have, and I don't think we're going to fix it tomorrow, and we can't wait to fix patient safety until we have a different kind of system. But it is to say that many of the early adopters and the early success stories do come from places that really are health care systems rather than the most haphazard arrangement.


    Let's talk about one more area which is beginning to be very topical, yet again, which is malpractice, and malpractice reform. Much of the message of the IOM report was that the old culture of blame, of sort of isolating blame at the door of a particular doctor or nurse, as we said earlier, is the wrong way to go, and that we need to understand that errors are usually the result of some systems failure, or lots of little failures taking place along a chain. As we move down the line of perhaps malpractice reform over the next few months, are we going in the wrong direction? Are we not understanding what really does generally cause errors in medicine, and how, more importantly, to tackle those and create a culture of true patient safety. Lucian?


    Absolutely, moving in the wrong direction. The biggest thing wrong with the malpractice tort system in terms of safety theory is it puts the focus entirely on the individual instead of on the system. And it's hard to see how that's going to change unless there are some very major changes in the whole concept of liability in states throughout the country, and that doesn't seem to be in the cards.

    But I think it's a much bigger issue than that. The emphasis on tort reform is to reduce the payments, and there are arguments on either side of that. I'm not going to come down for or against it. I can see both sides of that one. But that's not the solution to the malpractice problem.

    If you step back and say why do patients sue their doctors, well, they sue for three reasons. They sue because they've had an injury, they sue because they've had some major costs as a result of that injury, but most of all, they sue because they're angry. They sue because they're mad at the way they were treated.

    If we want to reduce the malpractice threat, we've got to deal with all three of those. Now, much of the safety movement has to do with number one — how can we reduce the injuries – and that's got to be our primary objective, and that's what we're all working on, and clearly that's going to be crucial. But we're always going to have some. We'll never be perfect. And so the next question is what about the payment. Why should the patient pay for the costs of my mistakes in treating them. And, of course, if you step back and look at that, you say, "Well, you know, that doesn't make sense."

    And one of the – in fact, the only recommendation from the medical practice study – the medical practice study was the big study that came out with the 98,000 figure back in the 1980s, and the only recommendation from that study was that we have a no-fault compensation scheme, much like they have in Sweden and New Zealand where if you have an injury from medical treatment, you get – you get paid for that, the cost of the injury. You're out of work for six months, they compensate you for that.

    If we were to do that in this country, number one is it wouldn't cost any more than what we're already spending on liability insurance. We showed that. We showed that the actual expenditure on liability insurance in New York State back in the 1980s when we did this was more than the cost of the medical injuries would be if you paid for all of the injuries. And the malpractice system only compensates one or two percent of the people with injuries. So we could compensate everybody for the same price.

    So it's not a matter of would it cost more, but if we did that, it would dramatically reduce the need for people to sue, just in terms of their expenses.

    The third item, I think, is the one we really have to focus on, and that is most people who have injuries don't sue. Most people who have expenses don't sue. Only a few do, and you ask them why, and time and time again it's – some of them say, "I did it to find out what happened." "You did it to find out what happened?" "Yes. Nobody would tell me."

    So the fact that nobody would tell them, first of all it doesn't seem right, but more than that, it makes them very angry. And many times patients' experience is that nobody will take responsibility, nobody will admit what happened, and nobody will say they're sorry. And you look at the mediation experience where patients meet with the mediator and the doctor and talk about it, and what do they say they want to do? They want to find out what happened, they want to hear the doctor say they're sorry, and they want to hear the doctor say what they're going to do to keep it from happening to somebody else.

    Patients are very interested in not having what happened to them happen to somebody else. It's a very, very common thing.

    So the question is how do we get there, and the answer is we've got to be much more upfront and honest when we talk with patients. We call it full disclosure, which means when we talk – when patients have something go wrong, we tell them what happened, we take responsibility for it, we keep them informed of what's going on, and we tell them what we're going to do to keep it from happening again. When hospitals have done that, their malpractice suits have plummeted. And we've got some very good experiences with that now that show that not only is honesty the best policy, it's the smart policy in terms of preventing suit.

    So I think we have to do all of these things. There's a big movement to improve disclosure. That's good. There's a big movement to reduce errors – that's good. We would like to see something happen in the compensation area, too. That's a – that's a political problem that's a little harder to do.


    I think the malpractice system is one of the thorniest issues in all of – in all of medicine, in all of patient safety. It is terribly demoralizing to doctors. My best friend is an obstetrician, and he is one of the most ethical, humanistic, bright people I know, and when you go talk to him and his colleagues about their practice, they went into obstetrics for the joy of delivering babies, and much of what they talk about is the malpractice problem. It's a terrible problem.

    I agree that I think the no-fault idea is a – is certainly worthy of experimentation and trial. Whether it is politically possible in this country, I'm skeptical about. I just can't see us moving to an environment where there is no finger pointing when there is a terrible error, because as it turns out, I'm a true believe in the system's theory of medical mistakes, that the progress that we will make here will mostly be through better systems. But until we come up, there also are some bad doctors and some bad nurses. It's not the crux of the problem, but there are – there are some. And we have to figure out another mechanism for accountability, and as long as the only one we have, because we don't seem to be capable of attacking that on its face, is the tort system, and I think we're stuck with the tort system.

    If we can move to a no-fault system for compensating patients for injuries, it has to be hand-in-hand with another system that says we are looking at doctors, and when doctors truly are careless and truly make multiple mistakes and don't learn from the mistakes, or don't follow simple safety rules, that there are consequences. And right now there really aren't significant consequences, and people know that, and I think that props up the malpractice system because it seems like that's the only tool that we have to deal with that. So I think there are kind of different problems.

    In terms of tort reform, the kinds of proposals that are on the table now, I'm generally in favor of because I think you're not going to be able to find an obstetrician or a neurosurgeon eventually. So I think at some point you need to do something to fix that problem, but I don't think it has very much to do with the general problem of medical errors. I don't think it's going to fix it in any significant way.


    Picking up on your comment about who we hold responsible, in most states right now the person to sue is the doctor because it's almost unlimited in terms of what you can get in settlements, whereas many states have restrictions on the liability of hospitals.

    We have that in Massachusetts. A hospital can't be held liable for more than $20,000, which in the malpractice world is nothing. That's got to change. If we really believe that the injuries are a result of systems failures, who's responsible for the system? The hospital. So therefore the hospital should be held responsible.

    If the hospital were held responsible, it's called enterprise liability, and no hospital wants to hear this, but if the hospital were responsible, then we would begin – the spotlight would change to the hospital. And if they had to pay for it, then there would be a lot more interest in doing two things. One is being more serious about safe practices, and the other is being more serious about identifying problem doctors earlier, before they get in trouble, and we can do that, and I think that would make a big difference, and we could do that without national legislation. We would need state legislation for that.

    I think that's a much more doable thing, and I think that's the first step towards coming to a no-fault compensation plan, to first establish who is the one that's responsible for the injury – it's the hospital. Once you establish that, then it's just another step to have a system where they pay for it.


    Let's assume it's 2009 and it's the tenth anniversary of the errors report. What changes do you think we will see in the next five years between now and 2009, Lucian?


    I think we'll have the computerized patient record by then. I think we'll sort it out. It's a big problem, but there's so much interest now and the interest has risen. I think we now have an IT czar with David Brailer, and I think there's a real commitment to moving ahead, so my hunch is we're going to be able to accomplish that in five years.

    I think we will continue to see more and more safe practices coming down the pike. The Joint Commission will continue to require their implementation. More importantly, they will be in pace and hospitals will be doing them, so that's going to make care safer.

    I think teamwork is here to stay. I think by five years it's going to be the norm and not the exception, and I think we can – in five years we'll also be in a point where patients will uniformly get the full story when something goes wrong.

    Patients have a right to know everything that happens to them. I think we all know that, and we're going to figure out a way to do it. So I think all those things are going to happen in the next five years.


    I hope so. I think those are all – those are all reasonable.


    You're all in favor of it.


    I'm in favor of all of those. I think the question will be the hospital that says it's doing teamwork training. Are they really training everybody, or have they done it in one small corner of the hospital? The hospital that says it has information technology, because now there's a lot of pressure to do it, do they have a system that a few people are using, or is every single order written on the – or typed into the computer?

    I think those – those – the amount to which – the extent to which these sort of practices really diffuse through the entire system, five years from now I think we're going to be further along than we are now, and I'm optimistic about that. But I think you still have this problem that is often referred to as the business case for safety, and the challenge is if I'm a hospital CEO and I have an extra million dollars left over at the end of the year, which sometimes these days they don't, but even if I do, what is rational for me to spend that money on? Is it more rational for me to spend it on teamwork training, which may be what it costs to train all of the members of my hospital staff, or to build a new operating room or to buy a new MRI scanner.

    I build a new operating room, I buy a new MRI scanner, patients are going to be coming through those things. They generate resources. It's all good, and none of those are bad things to invest in. So the question, I think, that really will be the determinant as to whether these things diffuse very broadly or in kind of narrow ways or only in the best of hospitals and not all hospitals is does that dynamic change so that a CEO or a hospital board can't wake up in the morning and not have done all the things they need to do to make themselves as safe as possible.

    Right now, even with all the attention on safety since the first IOM report, it is still not an irrational business decision not to invest in safety. It's an immoral decision. It's not ethical, but it's not an irrational business decision, and that has to change. It's beginning to change at the margins, but it still hasn't fully shifted. Until it does, I don't think we're going to see the level of investment that we need to in order to have full limitation of all those things.


    I think it's going to change for one reason, and that's the payers have gotten into the mix. The big buzz word now is pay for performance. Pay for performance means you do a better job, I'll pay you more. And safety is now on the screen. And the payers are very interested in safety because they have finally wakened up to the fact that when patients have injuries, they pay more. Health care is the only industry where you pay more for a defective product.

    And so the payers – the insurance companies are paying for that extra operation. They're paying for the extra ten days in the hospital. They're paying for the complication from the drug, and they've finally wakened up to the fact that it doesn't have to be that way, and that if they give – they give financial incentives to the implementation of safe practices, that they will end up reaping the reward from that investment.

    And the reason I feel so confident about the electronic health record, teamwork and some of these other inventions is I think the payers have begun to realize that if those things happen, they will benefit from it and they're going to pay for it. They're going to pay – I believe they're going to pay for the computerized patient record. They're going to pay not for teamwork, but they're going to pay for better outcomes that happen when you have teamwork. And if, for example, I can show that in my prenatal unit, my obstetrics and delivery unit that by teamwork I can reduce the complication rate by 50 percent, which is what Ben Sacks has shown at the Both Israel Hospital in Boston, the payers are going to say we are going to pay more for every obstetric unit that has teamwork because they know they're going to reap the reward. And that's why I think it's not going to be spotty, I think it's going to be universal to the extent that these things we think are important really work, because the bottom line is do they make a difference in safety. If they do, the payers are the ones who are very interested in that.

    So I think we've got a new – we've got a new player in the mix. We never before had the payers involved, and it's just been in the last few years they realized that it's in their interest as well as, obviously, all of our interest to pay for quality, and as they do that, it will drive the process.


    I hope. I really hope so. I think – I think the payers are very important, I think the institutions are very important. The key players, of course, are you and me as patients. And the question really is the degree to which patients will continue to push this agenda.

    Will a patient make a choice about going to Hospital A versus Hospital B based on their perception of that being a safe and that being an unsafe hospital, based on whether they're doing teamwork training, based on whether they have computerized themselves. And the answer today is no.

    Over time I think that's where the pressure has to come from. That's where the only way the state or federal legislation will come that's necessary, that's useful, the only way that the regulators will be as tough as they need to be in this field is if – if patients really get that it's their pressure that drives the system.

    In medicine there's always a little bit of a competition. It's easier to get funding if you say I'm here to improve care for diabetes, or for AIDS, or for hear disease because for each of those you have a constituency. You have a group of patients and families who have that disease, who have Alzheimers, and not to diminish that at all, it's incredibly important. But there really is no constituency for patient safety. You try to find a lobby of people who say I was harmed by a medical error and I'm pushing the system, and I'm rallying.

    There are a few very tiny groups, but there's no professional constituency and there's no group of patients that really are driving the system the same way. So I think the insurers are going to be an important part of it, but I think the big piece over time will be are patients saying to us the system that you have set up is fundamentally unsafe and we won't accept it anymore, and you folks better fix this, and here are the resources to help you, but we won't accept it the way it is. I think the jury is still out on that one.

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