How did I miss his hypokalemia? Two weeks into my intern year and my patient’s potassium returned at 2.9. Minutes later, he coded. And I felt responsible. As I explained to my partner how my patient had become pulseless after diuresis of his heart failure, she looked at me and said, “Physicians kill patients, it’s inevitable. Has no one told you it’s part of the job?”
There is truth to this bluntness.
According to a BMJ article from 2016, roughly 251,000 deaths occur every year as a result of medical error. If morbidity is factored in, this number skyrockets. You would think with such a staggering mortality rate, we as physicians would be more comfortable discussing medical error and our direct role in failing to prevent these avoidable deaths.
In 1999, the Institute of Medicine brought medical error in the public eye. It revealed that between 44,000 to 98,000 deaths occur from medical error every year. This number was astonishing enough to provoke President Bill Clinton to sign a Senate bill creating an agency to address the epidemic.
Over the next decade, data surfaced exposing how that number was grossly underestimated. Now data suggest the amount of deaths ranges from 210,000 to 400,000. This would make medical error the third leading cause of death in the United States, which makes it all the more surprising that we ignore it.
This data is challenging to collect because the CDC relies on ICD-10 codes placed on death certificates to compile the list of leading causes of death. Since medical error is not registered in the coding system, it is difficult to grasp the true magnitude of the issue.
However, what can be grasped is its impact on physicians. Dr. Danielle Ofri in her book, What Doctors Feel, describes how physician error feeds feelings of paralyzing shame, guilt, and imposter syndrome. Describing a personal near-miss experience, Dr. Ofri writes, “I spent weeks afterward flagellating my brain for its incompetence, berating myself for my idiocy.” Any medical professional can relate to this statement.
We are all human. We all make mistakes. Physicians may believe they are more careful than the average person, triple checking their actions, and developing a more critical eye. However, walking through the hospital doors and donning a white coat does not make us immune to error. We are all human.
We cannot expect to be perfect. Even if we were, perfection is not good enough. A JAMA article described that if other fields operated at a 0.01% error rate, that would equate to “2 unsafe plane landings per day at O’Hare, 16,000 pieces of lost mail every hour, 32,000 bank checks deducted from the wrong bank account every hour.” Yet none of this happens. Why? Because there are systems in place to prevent human error from causing harm.
A recent documentary, To Err is Human, explores the cultural issues behind medical error. Lack of transparency, an archaic hierarchical structure, and a focus on reprimanding all contribute to the problem. Furthermore, errors occur because systems are missing to catch human error.
However, there is change occurring in medicine. It just happens to be at a glacial rate.
To change the system, we have to become comfortable talking about error. It will help us cope with our mistakes and foster a culture of transparency, which is necessary to implement change. Furthermore, it will assist in obtaining accurate data on the causes of medical error, in hopes of preventing their future recurrences.
Currently, hospitals are utilizing root cause analysis to prevent medical error. However, what is needed is a change in the reporting culture. For example, NASA has a reporting system in place were near-misses are voluntarily reported and mistakes are mandatory to report. If hospitals implement such processes and encourage its use among physicians, more accurate data can be collected leading to more impactful policies aimed at preventing harm.
We have all encountered medical error. We have seen, and likely felt, its impact. So why not start acknowledging it?
It would be a shame to look back on these times and cringe at how barbaric our medical system was for allowing medical errors to persist. I would rather look back and be grateful that processes were created to prevent human fallibility from costing patient lives.
Michael Grzeskowiak is an internal medicine resident.
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