The problematic impact of To Err is Human

November, 1999 was a watershed for physicians. It is then that the infamous “To Err is Human” report was issued by the Institute of Medicine claiming that close to 100,000 patients were needlessly dying due to preventable medical errors. The report was a bombshell, having a significant impact on how medicine was practiced. 15 years later we are still evaluating that impact.

To anyone who took the time to read the report it was clear that it was problematic. However, being the complacent lemmings that we are, the report was accepted at face value. One problem was the fact that we as physicians failed to counteract the impression that we were at best complacent, at worst ignoring the effect these “errors” were having on our patients. Damage to our reputations and malpractice aside, the vast majority of physicians were well aware of these issues and were taking steps to prevent them.

However, there was a much bigger problem. Vague at best, the report failed to distinguish between an error and a complication. Wrong site surgeries, incorrect blood typing, and medication errors are, at least theoretically, 100% preventable. Post-op infections, DVT/PEs, however, are not. No matter. Once both got painted with the same brush the inevitable problems ensued.

After some initial success, a mad dash occurred to try and eliminate every so-called error. Medicares refusal to pay for these errors was one example. Worse still, when something was declared an error it immediately became a “never” event, something that had to be eliminated at all costs, even if that action put the patient at a different risk that is not considered.

Take venous thromboembolic prophylaxis. From the first days of orthopedic residency, we are well aware that our patients are at risk for blood clots in the legs with the possibility of death due one of those breaking off and lodging in the lungs (DVT/PE).

However, since the treatment involves giving the patients blood thinners, we are also well aware that there is a delicate balance between protecting the patient and preventing excessive bleeding. With time and experience, most surgeons learned what balance worked for them.

There is no way to completely eliminate DVT/PE risk. No matter. Once they were declared a never event a heavy thumb came down on the prevention  side of the scale meaning the bleeding side went straight up, aggravated by the fact that the bleeding risk is not considered by whatever protocol had been set up.

15 years later, most physicians are living under a mountain of protocols and have been able to evaluate the effect they have had on how they practice medicine. The conclusion: It is rare that the protocol actually improved upon what they were already doing. At best following the protocol confirmed what they were already doing. At worst they have found that the protocol puts their patients at additional and unnecessary risk.

Today, physicians are widely criticized for not being patient centered. We are losing the battle between a physician doing what their training and experience tells them what needs to be done, and towing the company line. “To Err is Human” may be true, but if we don’t properly identify what the “err” is, it does no one any good.

Thomas D. Guastavino is a physician.

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  • pmanner

    I posted this a while back, but it still applies.
    TEIH was based on two, count ‘em, two retrospective chart reviews. One looked at hospital discharges in New York in 1984, the other looked at hospital discharges in Colorado and Utah in 1991. Basically, a nurse looked through a stack of charts, and then a physician looked at the stuff she picked out.
    In both studies, adverse events occurred in about 3% of discharges, and the researchers decided whether these reflected negligence. About 25-30% did in their view.
    So we have created an entire industry, and justified an enormous and probably futile exercise in fingerpointing, because of two subjective chart review papers. From 30 years ago. Still do things the way you did in 1984? Didn’t think so.

    • ninguem

      Patient has terminal cancer, and will be dead within a week.

      Mabel on third shift gives the dying patient two Tylenol’s instead of one. It makes absolutely no difference, the poor patient is going to die no matter what you do.

      The patient dies of cancer. The error was duly reported and reviewed.

      The reviewers looked at the chart. Medical error, followed by death a few days later. The conclusion was that the error caused the death.

      And it has taken on a life of its own as pmanner points out.

  • SteveCaley

    I’ve actually been a fan of the guts of TEIH. The media pinwits picked up the number, and since they, they’ve treated doctors like the carneys in a travelling roadshow.
    The NCC-MERP protocols to reduce medication errors are terrific for use to prevent medical errors; but sadly, are only useful in another culture in another time. Eliminating errors requires redundancy, and that requires spare time. The country has gone at light-speed in the other direction.
    I was berated on a Health/Business website for suggesting that anaesthesiologists were indicated in colonoscopies if there were. say, a 3% need for their expert intervention. “Three Percent! What a waste of time and money,” chortled the business types.
    Back to NCC-MERP: The requirement is the ability to report errors CONFIDENTIALLY. And, sorry, that’s gone with the VHS and the eight-track tape, never to be seen again. The pocket recorder phone has killed peer review, M&M, and any discussion of anything suable.
    Errors are prevented by #1) continuity of care, and #2) redundancy. Ask any expert in fire control. Probably 70% of the firemen are sitting around the fire station at any time. But one does not staff for the average day – one staffs for the once-in-a-decade disaster.
    The pinwits with business health want to staff for the average – and TEIH says that’s disaster.
    TQM and other management systems say that >85% of systems failures are due to defects in systems design, and <15% are due to individual failures or deficits. Even that's probably a little harsh, in reality.
    If errors and complications were treated the same – as defects in the system – we might have made some headway in 15 years.
    But we went in the wrong direction, and medicine collapsed in the last 15 years, expensively too – and it’s too late to fix.

  • PoliticallyIncorrectMD

    Make no mistake about it. The whole industry of so called “patient safety” is based on this pseudoscience and fear mongering.

    • rbthe4th2

      Respectfully I disagree. There are a number of us who have been harmed due to a doctors’ missed or delayed dx. Of bias creeping into their judgements. That is what most people want: safety from those errors.

      • Thomas D Guastavino

        We physicians want this as well. Problem is the way we are going about it is not helping physicians or patients.

        • rbthe4th2

          Agreed. I think there are system problems, education problems. I would rather we work together and find ways of doing that, of getting physician and patient groups together, to explore and find answers.

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