The war on medical error was officially launched in 1999, when the Institute of Medicine (IOM) published its landmark report To Err is Human, alleging that up to 98,000 yearly deaths in US hospitals were due to human missteps.
Despite significant ambiguities in the definition of a medical error, numerous militias known as patient safety organizations (PSO) sprung up almost overnight to help combat the terrible enemy. Under the IOM’s strategic directive, and enforced by government regulators and private health insurers, PSO’s organized a counteroffensive that would aim to model health care institutions on the pattern set by the aviation industry.
The main weapons deployed in the war on error are ever-growing numbers of surgical checklists, procedural time outs, distraction-free safe zones, root-cause analyses, and other protocols and disciplines which must be implemented by hospital personnel with the same diligence as might be seen at Cape Canaveral.
Under the ever-watchful eye of the electronic health record, progress in this campaign is assessed with “scorecards” documenting adherence to the paramilitary discipline. Failure to comply can result in significant loss of income for hospitals and for medical practices, lest they harbor potential errorists. Needless to say, every administrator, every nurse, every physician, every pharmacist, and every orderly has been placed on red alert, if not put on notice.
After 15 years of this severe regimen, one would think that the potent measures would demonstrate some tangible progress. Instead, recent statements by the leader of one the most influential PSO’s in the country testify of a sobering reality.
Attendance at 2 Superbowls=# Medicare beneficiaries expected to die this year of hospital errors:http://ping.fm/kjhjx
— Leah Binder (@leahbinder) January 31, 2011
— Leah Binder (@leahbinder) April 7, 2011
— Leah Binder (@leahbinder) September 23, 2013
Food for thought
With an apparent 10-fold increase in medical errors since the advent of the patient safety movement, one may wonder if the methods employed to reduce complications, modeled on the achievements of the airline industry, are not themselves part of the problem.
After all, airplanes are artifacts of the human mind with a known blueprint and a pre-specified destination agreed upon by all involved. Human beings, on the other hand, are natural products of biological evolution or of the divine mind, have unfathomably complex designs, and display surprisingly self-directed behaviors.
In confusing the patient with the jumbo jet, could it be that PSOs needlessly distract health care personnel from their most precious and unpredictable cargo? Could it be that, enthralled by a grossly mistaken analogy, PSOs are in fact committing the biggest medical error of them all?
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