Reducing medical errors: What we can learn from the Dreamliner

Reducing medical errors: What we can learn from the Dreamliner

If you think that medical errors are a thing of the past, you are mistaken.

It has been 14 years since the Institute of Medicine’s report “To Err Is Human” shattered the myth that most, if not all, physicians are all-knowing practitioners with flawless skills and infallible judgment.

The story of what happened in the report’s wake was predictable:

  • Where the healthcare industry failed to act as it should have, the federal government and accrediting organizations stepped in to set the standards for healthcare quality and safety, establish quality measures, and assure that healthcare delivery entities complied by instituting financial and other penalties for poor performance.
  • Patients who previously felt safe began to question their healthcare providers.
  • We began to see some evidence of improvement in the quality and safety of healthcare services across the U.S.

In light of the foregoing, a recent “trip” to the website for American Medical News, the newspaper of the American Medical Association, left me feeling frustrated and sad.

A story by Kevin B. O’Reilly referred to a recent well-referenced article in Surgery, noting that, at the close of last year, “never events” continue to occur in U.S. operating rooms 80 times per week.

In addition to causing temporary or permanent harm to patients, he extrapolated that these events carry a financial burden of almost $1.3 billion over 20 years.

Although surgical “never events” are rare (i.e., one in every ~12,000 procedures), their seriousness should not be diminished — especially when simple checklists and protocols have been shown to reduce the occurrence of such mistakes to near zero.

According to the article, published findings of a review of medical liability settlements and judgments collected in the National Practitioner Data Bank for 1990 to 2010 revealed that surgeons of all ages are involved in “never events” such as inadvertently leaving surgical items in the patient, performing either the wrong procedure or the right procedure on the wrong site, and — most egregious of all — operating on the wrong patient.

Startling as this is, previous studies have found that the 90% of injured patients who do not receive indemnity payments are not even included in the data bank.

Other studies have shown that “never events” can be eliminated — or at least minimized — by intensifying focus on identifying and correcting deficient processes, for example by addressing communication lapses with presurgery briefings and marking operative sites.

To its credit, the Joint Commission’s Center for Transforming Healthcare launched a project in 2010 to reduce wrong-site surgery risk at eight healthcare organizations and to provide tools to help others prevent these mistakes.

After these organizations reduced the proportion of cases in which there was a process-related problem that could have resulted in a wrong-site surgery from 52% to 19%, the commission made a wrong-site surgery prevention toolkit available to its accredited hospitals at no cost.

A national surgical safety project — NoThing Left Behind — introduced a slight change in the process for counting sponges at the end of procedures and some organizations have adopted new technologies (e.g., bar-coded sponges) to address the problem of retained foreign bodies.

Despite these and other evidence-based efforts, surgical “never events” continue to occur at the rate of 4,160 every year.

Because patient safety is part and parcel of my daily routine — whether in the hospital, the classroom, or at a national meeting — I ask myself why our industry is not mortified and why, as a nation, we are not appalled.

When I look to the airline industry for analogies, as I often do, the Boeing 787 “Dreamliner” comes to mind.

After only a couple of incidents, the federal government grounded this newest, most technically sophisticated airliner until the problem was fully understood, the deficiency corrected, and the risk to passengers and crew minimized.

Shouldn’t we address surgical “never events”, which affect 4,160 patients each year, with the same urgency and gravity that we address the potential risk to 210-270 passengers of travelling in the “Dreamliner”?

David B. Nash is Founding Dean of the Jefferson School of Population Health at Thomas Jefferson University and blogs at Nash on Health Policy.

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  • azmd

    Based on what I have read so far about the Dreamliner debacle it appears that the story of how their lithium battery configuration got approved in the first place and the ongoing saga of what (if anything) will be done to remediate the aircraft’s flawed design, should hardly represent examples of good quality control for us in the medical profession.

    • Docbart

      How many people have died because of problems with the Dreamliner?

  • http://twitter.com/FerkhamPasha Ferkham pasha

    Is the Dreamliner back in service?

  • PoliticallyIncorrectMD

    Sure… Lets create another government agency to protect patients from doctors and “ground” all the US healthcare until we figure it out. I wonder how many patients would that effect. Or, perhaps, we should just except that ” to err is human”?

    • Hn

      Sure to err is human but we can surely find a mid way between stalling the whole thing vs. letting chips fall where they may?

  • http://www.facebook.com/steph271088 Stephanie Yong Tshun Yee

    Despite the surge of efforts by the Joint Commission International (JCI), little efforts are made to enforce compliance. Many healthcare institutions across the globe have not received these accolades, recognitions or accreditations but that does not stop them from running and treating millions of patients everyday. What we can do as professionals in the medical industry is to not only raise awareness amongst the healthcare workers and the Key Opinion Leaders (KOLs) running these institutions but raise a sense or urgency amongst the patients and consumers to demand for a healthcare system they deserve. Ultimately, the patients are the final consumers of our products and services.

    • PoliticallyIncorrectMD

      You are absolutely right: in spite of Joint Commision’s efforts there is no measurable decline in safety issues, eccidents, or hospital aquired infections. Perhaps this is not the issue of compliance but rather complete lack of common sense in most of Joint Commision requirements. And the solution you are offering is to “raise a sense or urgency amongst the patients and consumers to demand for a healthcare system they deserve”? Sure… Lets create panic and help politicians to come up with more costly and useless regulations which do nothing for safety but nevertheless sound great on campaign trail.

  • Docbart

    Unlike the airline industry, which has a great safety record, medicine does not have a culture of deliberately recording, analyzing and correcting errors. Instead of black boxes that record everything for later analysis, hospitals have “risk management” departments. Risk management certainly involves decreasing the risk of mishaps, but also functions to conceal evidence of mishaps from patients, families, lawyers and regulators. Recording the evidence of errors in discoverable medical records is taboo and total honesty with patients is considered questionable. How can you correct problems that are not acknowledged?

    • azmd

      Back in the days of the dinosaurs when I was in medical school, we had something called “Morbidity and Mortality Conference” in which adverse outcomes were reviewed and discussed in a non-punitive fashion in order to promote awareness of medical errors and to devise procedures which could help avert similar errors in the future. Am not sure why those appear to be less widely used these days but I suspect it has something to do with advice from lawyers, and possibly with the fact that any excess time that doctors and hospital administrators may have had to devote to these activities has been squeezed out of the budget in favor of clinical activities that are directly compensated.

      I think the bottom line is that until the federal government decides to provide funding for agencies similar to the FAA and the NTSB, which police the airline industry to track airline safety issues and investigate bad outcomes, it is unlikely that safety in medicine will approach the levels seen in the airline industry.

      Also, I would dispute the assertion that “total honesty with patients is considered questionable.” It’s my understanding that the standard these days is to disclose medical errors to patients and their families. On the one occasion in the last few years when I had a complication related to an error in the patient’s management, I called risk management to talk to them about the fact that I felt I should call the family and discuss the error with them. I was in no way discouraged from doing that.

      • Docbart

        I have been discouraged from revealing to patients the facts about ongoing problems in rendering care in the hospital setting.

        As for M & M, who can attend? The primary docs and many subspecialists don’t do inpatient work anymore, having abdicated to hospitalists. The hospitalists are in house when they are paid to be there, not otherwise, from what I see.

        The medical industry quality is to be tracked by the feds, much to the chagrin of many docs. If airline pilots emulated docs, they would use sign language to communicate, so the black box would be unable to record their comments.

        • http://twitter.com/LeanStepps Steve Montague

          The sign language comment is hilarious, but it’s true and it gets right to the heart of the matter. As an airline pilot whose been working with hospitals for the last ten years to improve safety and quality, I’ll tell you that docs and jet jocks are wired almost identically the same. The difference in behavior is due to the environment in which they practice.

          Pilots are rewarded for self-reporting, and almost all of the time they are not punished for errors, omissions, lapses, etc. If a pilot does not self-report, (s)he’s much more likely to be punished when these oops’ come to light. Physicians, and other practitioners, would probably appreciate this system.

          Pilots also begin debriefing their very first flight, and it’s just built into the system. This builds accountability, and humility, into the system as well. The only time a physician benefits from this type of review is when there is an untoward outcome, and perhaps on the aforementioned vanishing M&M.

        • EmilyAnon

          “I have been discouraged from revealing to patients the facts about ongoing problems in rendering care in the hospital setting. As for M & M, who can attend?”

          Aren’t you obligated to attend those M&M conferences if one of your cases is a topic of dicussion? I wonder if those sessions are as scathing as depicted in the TV show Monday Mornings. You would have to have a pretty thick skin to survive that.

          • Docbart

            I haven’t seen any evidence of M & M conferences at my community hospital. Acknowledging and confronting errors doesn’t seem to be part of the local culture.

  • Diagnosus

    Another analogy I have heard several times is that every week 3 jumbo jet crash worth of deaths occur due to medical errors. We would not be flying if such crashes occurred in reality but we still flock to the hospitals where similar number of people die because they chose to visit the hospital and would other wise have been ok. Must be the free market at work!

  • Bradley Evans

    The benefit of the Dreamliner is that people travel cheaper and more efficiently to their destination. So the cost of grounding it, is the cost of people travelling less efficiently and at more cost while it is grounded.

    The benefit of a surgery may be more difficult to measure, but what if a new surgery’s benefit is that 5000 more people live, compared to the old surgery, and the cost is 4500 more people die, because of errors related to the new surgery. So, if you ground this surgery, you have killed 500 people. The point is you have to look not only at the errors but at the benefits you are giving up by grounding the surgery.

  • ninguem

    Hey, no problem. Run the medical industry like the airline industry.

    The aircraft is too old, unsafe to fly. Scrap it.

    Do you want to scrap Grandma like the aircraft?