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The anatomy of medical error

Pat McNees. Updating our story below about the anatomy of medical error:
Medical Errors Are No. 3 Cause Of U.S Deaths, Researchers Say Medical errors rank behind heart disease and cancer as the third leading cause of death in the U.S., Johns Hopkins researchers say. "Medical mistakes that can lead to death range from surgical complications that go unrecognized to mix-ups with

the doses or types of medications patients receive. But no one knows the exact toll taken by medical errors. In significant part, that's because the coding system used by CDC to record death certificate data doesn't capture things like communication breakdowns, diagnostic errors and poor judgment that cost lives, the study says." (Marshall Allen, NPR, 5-3-16).

Are medical errors really the third most common cause of death in the U.S.? (David Gorski, Science-Based Medicine, 5-9-16) "Estimates of medical errors depend very much on how medical errors are defined, and whether a given death can be attributed to a medical error depends very much on how it is determined whether a death was preventable and whether a given medical error led to that death... These stories all refer to an article last week in BMJ by Martin A Makary and Michael Daniel entitled "Medical error—the third leading cause of death in the US,” which claims that over 251,000 people die in hospitals as a result of medical errors. Given that, according to the CDC, only 715,000 of those deaths occur in hospitals, if Makary and Daniel’s numbers are to be believed, some 35% of inpatient deaths are due to medical errors. That’s just one reason why there are a lot of problems with this article, but there are even more problems with how the results have been reported in the press and the recommendations made by the authors." Read the 400+ comments!

Superficial coverage of medical errors could leave erroneous impression with readers (Kevin Lomangino, Health News Review, 5-6-16) "...But the problems run deeper than ambiguous headlines. As the blogger known as Skeptical Scalpel (a self-described former chairman of surgery) points out, the BMJ paper takes some pretty big leaps to come up with its new national total for error-related deaths. And the idea that all of these deaths are entirely preventable is also open to debate, he observes." See Are there really 250,000 preventable deaths per year in US hospitals? (Skeptical Scalpel, 5-5-16) "Whether a death is preventable or not is often subjective and may depend upon the completeness of records and the "hindsight bias" of the reviewers. ...Medical errors do occur, and they should be identified and prevented. Makary's essay shines no new light, only heat, on the subject."

Medical Errors No. 3 Cause of Death in U.S. Candy Sagon, AARP, 5-4-16)"So what can patients do to protect themselves from medical errors? The nonprofit Hospital Safety Score has a number of good tips, including bringing a friend or family member along to ask questions and deal with problems, and making sure to ask about any type of medication you are given" (or treatment to pursue).''

Hospital discharge: It’s one of the most dangerous periods for patients (Jordan Rau, Washington Post, 4-29-16) "Bad coordination often plagues patients’ transition to the care of home health agencies as well as to nursing homes and other professionals charged with helping them recuperate, studies show....“The most risky transition is from hospital to home with the additional need for home care services, and that’s the one we know the least about.” "...one of the most common complications for discharged patients. The federal government views them as “a major patient safety and public health issue,” and a Kaiser Health News analysis of government records shows such errors are frequently missed by home health agencies. Between January 2010 and July 2015, the analysis found, inspectors identified 3,016 home health agencies — nearly a quarter of all those examined by Medicare — that had inadequately reviewed or tracked medications for new patients. In some cases, nurses failed to realize that patients were taking potentially dangerous combinations of drugs, risking abnormal heart rhythms, bleeding, kidney damage and seizures." " Of the $30 billion that Congress appropriated to help shift the system to electronic medical records — to ensure better coordination of care and reduce errors across the board — none went to nursing homes, rehabilitation facilities or providers working with individuals in their homes."

• If not for flawed tracking, medical mistakes would be the third-leading cause of death, researchers at Johns Hopkins say. Study Urges CDC to Revise Count of Deaths from Medical Error ( Marshall Allen and Olga Pierce, Pro Publica, 5-3-16),

• Betsy Lehman, a Boston Globe health columnist, died 20 years ago as a result of a massive chemotherapy overdose given in error.
My Father, Your Mother/Child/Cousin? Medical Mistakes Affect Millions Nationwide (Richard Knox, WBUR's CommonHealth Reform and Reality, 12-5-14)

20 Tips to Help Prevent Medical Errors: Patient Fact Sheet (Agency for Healthcare Research and Quality)

10 Ways to Save Your Life or the Life of a Loved One (Jamie Leigh Wells, Huff Post, 5-3-16) Don't be complacent or allow yourself to be unduly influenced and make decisions based on minor inconveniences. Do things right the first time and systematically every time. Keep records in real time in a notebook by the bedside. Write down everyone who engages and when. Ask questions: What drug is that? Do not leave a family member alone in the hospital. Get copies of medical records as available. Have third party as objective observer; patients cannot absorb it all. The seemingly mundane tasks of coordinating details can be a tremendously significant and meaningful way to assuage fears and lighten the load. Interview caregiver. Eliminate the term "primary care provider." (JAMA article). Call them what they are: a physician assistant, a nurse, a doctor. Don’t swoon over an institution or “world-renowned” titles. (There are stinkers in the best of places, and people who make mistakes.) Encourage a reasonable and realistic continuity of care (not too many cooks in the kitchen). You are important: tell everything you know; know the name of every medication you take. Keep your own summary of your health in a concise front/back sheet to keep in wallet and make copies to give out to caregivers. "Include timeline that lists all name/contact information of physicians seen and for what, when started and stopped meds, recent & past medical history, family & social history, surgical history, allergies (food, drug, environmental exposure and reaction type), hospitalizations, ER visits (contact info) etc."

Pat McNees wrote the following article for NIH Clinical Center News, September 2006. It appeared as "Expert explores the anatomy of medical error"

“Humans err,” said Dr. Saul N. Weingart, vice president for patient safety and director of the Center for Patient Safety at Dana-Farber Cancer Institute. “Training, communicating, and reminding are weak interventions,” said Weingart in a sweeping analysis of medical error, in a Grand Rounds lecture for NIH fellows in the Clinical Center last month. “Only by probing deeply can we understand the conditions that lined up to allow something unfortunate to happen. You’ve got to change the system.”

“Don’t rely on memory or vigilance,” said Weingart, “or expect people to perform well when fatigued.” Simplify routines, reduce handoffs, build in redundancies and provide better information. Create forcing functions (making it impossible to do action B without precondition A). Make use of best practices—bar coding, for example, and repeating verbal orders (“the Starbucks rule: I’d like a low-fat no-foam latte”).

Recognize missteps for what they are. Cognitive psychologists recognize three models of error in human performance; skill-based, rule-based, and knowledge-based. Human factor scientists call skill-based errors slips and rule-based and knowledge-based errors mistakes.

Skill-based behavior is rapid, effortless, unconscious—things you do automatically, such as brushing your teeth, buttoning your shirt, driving to work. Characteristic slips involve
· Capture (you’re supposed to do one sequence of steps, A,B,C,F, and instead you do ABCD, because ABCD is more common—as when you load up the family car for vacation and absentmindedly drive toward the office)
· Description error (correct action, wrong object—pouring syrup in your coffee or milk on your pancakes)
· Associative activation (having the wrong cue trigger a particular behavior—the doorbell rings and you answer the phone)
· Loss of activation (striding purposefully into a room and not remembering why you are there).

“These slips are common across all cultures,” says Weingart. “They are part of the human phenotype.” We’re built to perform many functions on an unconscious level so that we can think about other things that are more interesting and important. “But those automatisms allow us to get into trouble. And they are degraded by the things you’d expect, such as fatigue, illness, alcohol, sleep deprivation, and boredom.”

Rule-based behavior (when it’s raining, take an umbrella) is important in medical training. Using mnenomics, we train physicians in rule-based behaviors with code algorithms, said Weingart. “The trick is to apply it in the correct setting.” Rule-based mistakes occur when we apply the wrong rule — for example, going down a code algorithm but choosing the wrong arm.

Knowledge-based behavior involves solving novel problems, coming at them afresh. Knowledge-based mistakes, of which there are many, have to do with biased memory and intellectual convenience. We like to use the solution we used last time, or we don’t like to change our mind once we’ve come up with an initial hypothesis, or we’re overconfident about what we decide.

Knowing we are faulty machines and that errors are inevitable, said Weingart, we must design medical care systems that make those errors transparent and reduce the number of preventable adverse events and close calls—paying special attention to high-risk patients, “those with the least physiological reserve.”

It’s important, says Weingart, to take care of yourself, take care of the system, and reduce blame and shame. “If we’re not free to talk about errors,” he said, “we’ll never learn from them.”

Saul N. Weingart, MD, PhD, a national expert on reducing the prevalence and burden of medical error, is vice president for patient safety and director of the Center for Patient Safety at the Dana-Farber Cancer Institute and an associate professor at Harvard Medical School. He lectured in Lipsett Auditorium on August 2, 2006.

For a fuller discussion of the three models, see Lucius Leape, “Error in Medicine” JAMA, Dec. 21, 1994, 1851-57.
See also:
Institute of Medicine report, Reducing Medical Errors
More stories about medical error and quality control

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