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    Book Review

     Winter 2009

  
   
    Understanding Patient Safety
     By Robert M. Wachter, MD
     McGraw Hill Medical, New York et al., pp.298, 2008

     Dr. Wachter, Associate Chairman of the Department of Medicine at UCSF and author of Internal
    Bleeding, returns with a thoughtful yet concise analysis of patient safety and how to improve it.
    "To err is human" is the theme of the treatise although to forgive may not be so divine, at least
    as practiced in the modern medical system. The author approaches the topic in semi-tabular form
    with lots of charts and tables to illustrate the points of the text. He adds case histories as well in
    his broad yet precise attention to various medical errors.

    The book is divided into three major sections: basic principles of patient safety and definition of terms;
    specific types of medical errors; and solutions. Each chapter, in textbook fashion, ends with a list
    of key points and suggestions for additional reading. The initial section describes the astounding
    number of medical errors resulting in some 44,000-98,000 deaths annually as reported by the U.S.
    Institute of Medicine in 1999. Definition of general types of medical errors: preventable vs. non-
    preventable, patient safety as distinct from quality of care, the so-called "Swiss cheese" model of
    medical errors (the lack of redundancy to prevent mistakes) that results in such "never" events as
    operating on the wrong patient or the wrong limb or administrating a lethal medication dose to a
    patient, often due to similarities in the container or name of the drug.

    The types of medical errors are too numerous for discussion here. Many are obvious: wrong medicine,
    wrong anesthesia or retained sponges or surgical instruments, missing diagnoses which may be fatal
    such as a heart attack, poor communication and patient handoff errors, failure of human-machine
    interactions, nosocomial (hospital acquired) infections, poor teamwork and fatigued caregivers. These
    are analyzed along with several others and the cause and potential remedies are explored.

    Two important concepts the author explores are "forcing function" and "heuristic engineering." These
    address medical machine design flaws that may be modified to preclude errors: different size
    receptacle sites for tubing on anesthesia machines to avoid administering the wrong gas, color coding
    wiring to avoid electrical hazards, using pharmacy imprinted bar codes to be read at the bedside
    to insure the proper dose and the right patient. The idea is to build in a system of redundancy that
    will prevent the common errors: checklists, read backs of orders, patient handoff modules embedded
    in electronic medical records, computerized prescribing of drugs and procedures, avoiding abbreviations
    and jargon, marking surgical sites. All of these and many more are presented and analyzed.

    The section of solutions is perhaps the most important and valuable portion of the book. Here Dr.   
    Wachter discusses use of such things as information technology and computerization of patient
    records and prescribing; workforce and training issues; incident reporting and management; malpractice
    and the no-fault system replacing the tort-based one; various laws and accountability methods; and
    organizing safety programs with patient participation. A very useful appendix concludes the volume.

    As medical care becomes more sophisticated and costs skyrocket, the need for patient safety only
    increases. Compared to the aviation industry or even manufacturing, the medical establishment and
    physicians in particular have been slow to adopt safety measures to preclude adverse events. This
    book presents a careful review and useful suggestions for ameliorating this sluggish approach.

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