|
|
MedicoLegal
Consultants |
|
|
Book Review Spring 2004
This is an important book from several points of view. Written by two University of California at San Francisco professors of medicine, it combines an excellent blend of scholarly research, innovative analysis and personal experience to address the problem of medical errors. Ever since the Institute of Medicine's 1999 headline gathering report that 48,000-98,000 people are killed in American hospitals by medical errors annually, there has been an increasing demand for a solution. This problem is inextricably linked to other items in the health care agenda commanding public attention and bedeviling easy solution: uninsured patients, medical racial discrimination, the malpractice crisis, immigrant influx and the growing corporatization of medical care. Most of us assume that the lion's share of medical errors are of the personal responsibility type: mistakes largely made by the doers in medicine: the doctors and nurses who take care of us, or in the author's extensive analogy with the chisel, the "sharp-end" workers. But Doctors Wachter and Shojania tend to emphasize the systemic problems within the medical system, especially those in big hospitals, that lead to the errors: wrong medications or doses, bad "hand-offs" between healthcare personnel, wrong patient or operative site, overworked interns and residents and poor communication at every level. This they refer to as the "blunt-end" in the chisel analogy. Sometimes this is a result of silly bureaucratic rules that are ignored or ones that are inadequate to prevent common errors. Some solutions may be technological, preventing errors by good design and new equipment: computerized physician ordering to prevent errors arising from wrong doses, adverse drug interactions or bad handwriting; bar code confirmation of patient identity and signing or direct marking of surgical sites to prevent operating on the wrong patient or taking off the wrong leg; direct digital input of vital signs, critical lab data and medical records to render their immediate availability to all health workers involved in a patient's care. One of the strengths of the authors review is their comparison of the safety measures in the medical system with those of other high stress, high performance occupations: aviation, antiterrorism, high end engineering or law enforcement. Inevitably, the medical system comes out as indolent, poorly planned and sluggish in its adoption of new and better ways of doing things. This seems a giant paradox in view of the miraculous new drugs and surgical techniques on the substantive side of medicine. Yet one need only consider the book's detailed description of what went wrong in the Jesica Santillan case where the unfortunate girl received a heart transplant from a donor with an incompatible blood type. Despite the presence of a star transplant surgeon and an institution of the highest reputation with lots of experience, the failure to check the blood type of the donor (A) against that of the recipient (O) at several points in the heart's journey from Massachusetts to Duke University resulted in disaster. As is so often the case with medical errors, there was the assumption that someone else did it. Foreseeability, that critical item in the negligence chain, is often not considered by the blunt end team that is responsible for administration or supervision. The redundancy of safety measures characteristic of, say, aviation, is usually not found in medicine. The authors describe a case of an out-of-order elevator and hospital corridor construction that delayed the transfer of a patient from the floor to the ICU long enough insure her death. No one had thought to develop an alternative route and promulgate it in advance. In fact, the team approach is emphasized by the authors, especially in those critical care areas of medicine: the ER, ICU, OR, code blue situations. Here practice may not make perfect but it sure helps. Malpractice is given an interesting and important discussion. Sometimes it is, as most believe, a matter of incompetence or simple failure to take appropriate precaution or action. All too often it arises out of defects in "the system" that almost guarantee sooner or later there will be a mistake. The authors also indict the tort system and suggest a disconnect between who is at fault and victim compensation, perhaps some sort of no fault system that will allow compensation to victims without the blame and shame of the perpetrator. This might allow a more public airing of medical errors and lead to strategies for their solution. As it is, errors and "near-misses" are often covered up to avoid malpractice actions. The conversion to at least a partial no fault system with lawsuits reserved for only the most egregious and harmful errors deserves some consideration. How changing the tort system to a no-fault principle could be made compatible with the contingency system and the thousands of personal injury attorneys' need to make a living is not addressed. The experience of New Zealand and Sweden with no fault are cited, including the problem of replacing lawyers and judges with bureaucratic administrators and case managers. In short, the book recommends a culture of safety similar to that developed in industrial fields and aviation. Perhaps a medical "patient safety officer" is needed as a full time hospitalist, a doctor, not an administrator. The authors acknowledge that overcoming the elitist rugged individualism culture of medicine will not be easy. After all, look at the physician response to HMO regulation and rules. Still, matters are improving, albeit slowly. The authors do offer some other solutions. One intriguing idea is borrowed, paradoxically, from the struggle against HIV/AIDS. Hardly a paradigm for a successful public health effort in its early years, the results over the past few years, while not curative, have been remarkable with a decrease in mortality of 80% over a five year period from the late 1990s to the early 21st century. Unfortunately medical errors are diverse in nature and widespread in occurrence and do not have a charismatic spokesperson or poster-child or a well-established government entity to "get the message out." But the principle remains: government funding and public policy choices along with apposite publicity are required. This constitutes a difficult task in a market that must compete with terrorism and war and unemployment and the host of other items that demand the public's attention, not to speak of a federal budget that is $500 billion in the hole. Almost as if it were an advertisement for the book, an article about a medication error appears on the front page of the February 26th Los Angeles Times, quoting Dr. Wachter's comments. Still, hope springs eternal, at least in the authors' view. Much will be required of all elements of the system, blunt and sharp end types, to borrow the book's analogy. They end on a note of guarded optimism. Let's hope they are correct. |
