Why punishing medical mistakes won’t make patients safer

An interesting story came across my desk recently. Apparently, some states in the U.S. have moved towards a punitive model in trying deal with medical errors and adverse outcomes – this particular story describes how Utah will no longer fund healthcare providers and hospitals for dealing with illnesses that resulted from avoidable errors and infections.

On the surface, it kind of makes sense – one should be punished for making a mistake, right? Other goods and services industries guarantee their work, so why not medicine? But here’s the kicker: since June 2011, when medical errors were “mandated” to be reported, only 17 such events have been disclosed in the whole state of Utah that would potentially fall under this punitive model.

There is absolutely no way that there were only 17 avoidable medical errors in the whole state of Utah over the course of a year.

In reality, healthcare professionals make mistakes. Daily. Medicine is still very much a skill-based profession, and as such is at constant risk for human errors. It is normal. The trouble is, identifying and preventing them is a very complex issue; a process that is still very much in its infancy in the medical field.

The first difficulty is in recognizing when errors occur. Most mistakes made by healthcare professionals go unnoticed because they usually do not lead to an appreciable adverse outcome. Some of you may be familiar with the Swiss-cheese model of adverse events; because of the multitude of steps involved in a patient’s care (i.e. different levels of “safeguards”), it usually takes a series of errors to align before an adverse outcome materializes.

Imagine this scenario:

A cancer patient presents to a busy oncology clinic for assessment and initiation of chemotherapy treatment. The physician writes an order for the chemotherapy drug, but the handwriting is suboptimal and it is difficult to make out where the decimal point is in the dosage: is that 0.10 or 1.0? The nurse happens to be a new nurse, who decides to ask a more senior nurse to help decipher the writing, since the physician is already swarmed with an overflowing list of patients. They agree that it most likely is 1.0, and the nurse goes on to set up the infusion pump. Incidentally, the hospital has just switched to a new vendor for its infusion pumps, and all the staff are just learning how to program the machines. The nurse unintentionally enters a dose of 10.0, which is well above the normal limits of this particular chemo – however the machines were not designed to have automatic safeguards to prevent programming of excessive doses. The patient ended up receiving 100x the intended dose of chemotherapy, and passed away shortly after the error(s) were identified too late.

Who’s at fault here? And if it’s more than one individual, how much of the “blame” should each be accountable (and perhaps punishable) for? We now enter the next great difficulty in trying to use a punitive model to address medical errors: the complexity of how errors occur in medicine means that true analysis of them require honest self-reflection and reporting. In other words, the culture of how we view and approach medical errors must first shift away from the traditional shame-based paradigm (check out Brian Goldman’s excellent TED talk on this topic).

And this can only happen in a safe and protected environment, where medical mistakes can be openly discussed so that everyone can learn from them. Otherwise things will only get swept under the rug, and you end up with ridiculous numbers like 17 errors in a whole year.

Punishing hospitals and healthcare providers for adverse events will, in my mind, only drive us in the wrong direction in tackling and preventing future medical errors.

Edmund Kwok is an emergency physician in Canada who blogs at the Front Door to Healthcare.

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  • http://twitter.com/Broselow James Broselow, MD

    As a new emergency physician in the 1980s I recognized that it was virtually impossible to treat safely certain acute pediatric emergencies when they presented to the Paramedic in the field or in the emergency department. Every dose of every medication had to be individually calculated depending on the weight of the child. Each drug and indication had a different formula expressed in decimal points. They all looked alike. Once the dose was determined, further math was needed to calculate the volumes to be drawn up, usually tiny volumes in small syringes. Also what size airway tubes, ventilator settings, infusion settings, fluids would meet the specific needs of the tiniest child to an adolescent? All of this in the setting of a child struggling for his life! Working with others we ultimately developed a simple tape measure (Broselow Tape) that determined the exact dose from measuring the child’s length, color coded it for equipment and put the right sizes in the right color drawer to be ready when the emergency rolled in.
    Once this approach was in place it became clear in retrospect that we had been working in a “bad system” and that in that environment there was 100 % probabilities that a dedicated, intelligent and conscientious professional would make errors. Should that person be punished for being human (getting 90 in a math test instead of 100?) How about 99 or even 99.9? That is still one in 1000 doses and the mistake could be fatal. Some children’s hospitals give a million or more doses in a year.
    Should a professional be reprimanded if they have such a system in place, but decided to override it and figure everything out on the fly? Perhaps they should. In the long run, however, to significantly impact these errors we need to remove human error as much as possible. Basically all mathematics should be removed from medication administration. Whenever math is part of a critical process we are actually forcing people to make mistakes. This is possible with modern technology but requires a huge amount of work up front to standardize the whole medication administration process. It is not enough to have people use “calculators” to solve these problems because they can enter the decimal point wrong, write the wrong equation, or enter the data incorrectly. Since the development of the Tape in the 1980s we have been working to develop technology (Artemis at eBroselow) that will ultimately remove all calculations from the process of medications administration. Hopefully in such a world these particular mistakes could be eliminated…no need to report at all!

  • http://www.facebook.com/DianeBarnes56 Diane Barnes

    It is vital for facilities to share information about serious errors. This allows other facilities to learn and make changes before they experience a similar error. Making individuals or facilities afraid to report problems will NOT improve patient safety.

  • Collegekid1592

    I think everyone should learn from their mistakes and the mistakes of others. If people are afraid to admit when they make a mistake, it will lead to people making extreme errors over and over because they are too afraid to admit they made the mistake one time so they just keep on making it because they don’t want to get help/corrected.

  • karen3

    180,000 Medicare recipients die every year due to medical error. Nothing is improving. What it is going to take for the medical community to understand that it needs to address system lying and to impose consequences. Is the “kumbaya” approach working? Because I will tell you this, the 100+ medical professionals whose incompetance and lack of spine caused my mother’s death, under circumstances that would in any other situation would result in felony convictions, knew darn well what they were doing.

    I have a question for you. How well does the model you promote work in other circumstances. Did you ever discipline your kids? Do you like hanging out with kids whose parents don’t discipline them? Do you think we ought to close the jails, because after all, a great deal of the evidence used to convict people comes from other criminals and if we got rid of jails, we’d have alot more closed criminal cases? How about an entirely voluntary tax system with no penalties. We all are patriots, after all. Let’s get rid of grading in schools and all penalties for not doing your schoolwork. In fact, lets just get rid of the rules against practicing medicine without a license or needing a doctor’s prescription for medications, because we know all humans have other’ people’s best at heart.

    How about instead we impose very serious penalties on lying. And impose serious penalties if you are in the chain of reposibility. Why, because people tend to be alot more vocal when its not someone else’s problem, but their own fat that’s likely to end in the fryer.

    How’s that voluntary, no consequence system working. Because it appears to me to be an abject failure.

    • nins

      If the one pushing this law can identify the exact dose of medicine to be given to all patients without causing adverse effects at the same time providing optimal therapeutic levels. Then let this law be implemented. For every medication you give there is a corresponding adverse effect. Even vitamins can give you one hell of a problem even in its right dose if you are unlucky. The practice of medicine is not an exact science. The bottom line of all these is that all physicians give their treatment in good faith. How can you punish someone who tries to help people who are suffering from their illness? If the time comes that robots and computers thinks about treatment and execute them without a tiny error, that will be the only time you can implement this law.

      Im a doctor and i have relatives who was also mismanaged by other physicians. I did not sue them. Why? Because i am aware that all they want to accomplish is to cure. Compensation is just a reward but never a pre-requisite to treatment. Maybe the real problem starts when the patient or his/her relative starts to lose trust to their physician. If patients will lose trust to their doctors, no matter how good the doctor is, the management will always be suboptimal based on the perception of patients or their love ones.

  • karen3

    And by the way, “not funding” is not punitive. It is just the normal consequences of someone having the purse strings. If you hire someone to paint your house and they don’t do it, or slop red paint everywhere, not paying them and having them pay the cost of clean up is not a punitive measure. Fining them an extra $5000 and having them spend the night in jail is. It is really a bizarre idea to think that if you do a bad job of something, you should get paid no matter what.

    Look at this video and tell me if you think “an apology” or continuing care provided with apron strings, or a lets all get together workshop with group counseling so that we all love each other is fair in this situation.https://vimeo.com/46597387. I don’t think this family cares one bit about a doctor feeling bad. I suspect that they care alot more about the life of disability that their children will endure. Why have the concern about how we are going to divide up responsibility. How about everyone man’s up. If the nurses in your example realized that they were likely to lose their licenses permanently for the misinterpreting the bad handwriting, my bet is that they would have made doctor fix the order instead of huddling out a potentially bad solution. And if Dr. Doofus realized he would be stuck with no license and $200k in debt, he’d invest in a handwriting coach.

    And think this one through. If you got stuck holding the monetary bag for a crappy hospital’s mistake, and there was a non-crappy hospital down the street, where would you work? My bet is that the extra $X in compensation wouldn’t be worth the risk. and if crappy hospital can’t hire, they won’t be in business. At the end of the day, it really doesn’t matter who in the medical professional gets stuck holding the bag, it matters more that the patients’ don’t.