How hard can it be to make sure you’re doing the right procedure on the right patient? You’d think this would be supremely basic, but apparently – in spite of all the emphasis on patient safety and the establishment of time-outs and other protocols – it remains beyond the grasp of many medical teams.
There was depressing news from Colorado recently. In a study published last month in the Archives of Surgery, 25 wrong-patient procedures and 107 wrong-site procedures were performed over six years, from the beginning of 2002 to mid-2008. These were not minor “oops” events. In five of the procedures done on the wrong patient and 38 of the procedures done on the wrong site, significant harm resulted to the patient, the study’s authors reported. In one case, a patient died.
Wait, there’s more: Last week the New England Journal of Medicine came out with another study, this time from North Carolina, that found harm to hospitalized patients was common and, as the authors delicately put it, there was “little evidence of widespread improvement.” Although most of the reported harms were temporary and/or treatable, 2.4 percent caused or contributed to the patient’s death.
And here in Minnesota, the first state to require hospitals and surgery centers to report adverse events, there’s been little significant improvement. Although fewer serious fall-related injuries took place in 2009, the number of wrong-site surgeries actually went up from the previous year. There was virtually no change in the incidence of retained foreign objects after surgery or the incidence of serious pressure ulcers.
We might have expected to see these kinds of statistics 15 years ago, when medical harm was rarely discussed openly and few, if any, systems were in place to help ensure safer practices. But not in 2010. I mean, come on. It’s been more than a decade since the publication of the Institute of Medicine’s landmark report on medical error, “To Err Is Human,” blew open the doors on the bad things that often befall patients and sparked a nationwide patient safety movement.
It’s disappointing and dismaying.
To be sure, patient care is complicated. It takes relentless focus and hard work to get it right. Dr. Bob Wachter, one of the smartest and most knowledgeable authorities in the U.S. about patient safety, offers this assessment:
Lots of good people and institutions have spent countless hours and dollars trying to improve safety. Why isn’t it working better?
I think the study tells us something we’ve already figured out: that improving safety is damn hard. Sure, we can ask patients their names before an invasive procedure, or require a time out before surgery. But we’re coming to understand that to make a real, enduring difference in safety, we have to transform the culture of our healthcare world – to get providers to develop new ways of talking to each other and new instincts when they spot errors and unsafe conditions.
Dr. Wachter has nailed one of the most difficult and elusive elements in patient safety: the culture of health care. On the one hand, the mandate is “First, do no harm.” But on the other hand, there’s often a tacit belief that harm is the price patients sometimes must pay for medical intervention.
How else to explain the stubborn persistence of serious and grievous errors? Here’s just one example: Vincristine, a drug used for treating several different types of cancer, is toxic to the central nervous system and should only be given intravenously. If it’s injected into the spine, it causes paralysis, coma and usually death. It’s not a pleasant way for a patient to die and it’s not pleasant to observe either.
This is not a rare or novel drug. It has been in use for more than 40 years and its inclusion is standard in many chemotherapy regimens. The risks of injecting vincristine into the spine are well known among cancer specialists. The damage is almost always irreversible and the vast majority of victims die. Yet despite this knowledge, despite warnings printed on the package overwrap, despite a myriad of safety recommendations, tragic mistakes continue to happen. From 2001 to 2005, there were two reported cases in the United States of vincristine being accidentally injected into the patient’s spine. There were five instances in Europe and one in Australia. Every single one of these patients died – and these are just the cases we know about.
You could argue that patients who undergo cancer treatment should understand and accept the risks that accompany chemotherapy. But I’m dead certain that being paralyzed by a preventable error involving vincristine is not, by most patients’ standards, part of this bargain.
It’s one thing to talk about the importance of safety. It’s quite another thing to actually internalize it and to integrate it in every process in the health care organization. One of Dr. Wachter’s commenters puts it very bluntly: Many providers don’t take safety seriously enough. She writes, “We have to build a generation that truly believes from the bottom of their hearts ‘that just because medical errors happen does not mean they must happen!'”
Here’s more from Dr. Wachter:
Organizations need to learn the right mix of sharing stories and sharing data. They need to embrace evidence-based improvement practices, while being skeptical of practices that seem like good ideas but haven’t been fully tested. And policymakers and payers need to create an environment that promotes all of this work – policies that don’t tolerate the status quo but steer clear of overly burdensome regulations that strangle innovation and enthusiasm.
Are we ever going to eliminate medical harm? The answer is no. Medicine is complex and every patient and every situation is to some degree unique. Perfection is neither possible nor realistic. Too often, however, health care is faulty and error-prone, and too many within the industry accept this as a necessary evil rather than striving for improvement. I can only wonder why the public hasn’t risen up in collective outrage and demanded better.
West Central Tribune file photo