Thursday, May 5, 2016

“Medical Error The Third Leading Cause of Death in the US”

Medical Error The Third Leading Cause of Death in the US

Makary and Daniel (Johns Hopkins) recently published a paper in the BMJ titled “Medical error—the third leading cause of death in the US”.   Their paper reiterates what many have had concerns about over the past decade or so: in spite of our best efforts, it is not clear that over the past decade we have made significant progress in eliminating adverse events in our Hospitals. If that is not enough, anyone who follows safety concerns/events on Twitter and other social media, will recognize that the public is made acutely aware of these facts on a daily basis (“Hospital probed after patient catches fire during surgery” May 5 2016- HorrorFansClub). Dr. Makary’s name may be familiar in that he and the Johns Hopkins group have been involved in projects over the past several years, evaluating teamwork and briefings in the O.R. (long list on Pubmed).

           This was a timely paper in that at our recent 40th Annual meeting of the Association of VA Surgeons, Dr. LD Britt, past president of the American College of Surgeons and current member of the Joint Commission, expressed concerns that as a nation we have not made significant headway in the limitation of adverse events or their consequences and issued a challenge to the AVAS and VA to address this head on. On that note, this past Summer Doug Paul and I discussed a NCPS paper that reported the multitude of factors leading to adverse event that originate either prior to after the universal protocol (upstream and downstream). Following this conversation we initiated a collaborative assessing wrong level spine and pain intervention. The key conclusion of this initiative was that we can implement as many policies, rules, regulations and technology that we desire but without humans taking the initiative to understand the implications of human factors in the creation of mistakes we will likely not make further progress.

In their paper, Makary and Daniel proposed 3 strategies to reduce death from medical care:

  1. Making errors more visible when they occur so their effects can be intercepted (end the shame and blame technique);
  2. Having remedies at hand to rescue patients  (discuss upfront potential issues that could create a mistake, their consequences and how we will handle that);
  3. Making errors less frequent by following principles that take human limitations into account (fig 2) (make it easier for people by identifying the more likely positions in a process that we will make a critical error, create a pause, assure everything is ok and then proceed).

I have discussed this with educators and we don’t want to cripple people by making them overthink every single process but focus on the very critical points and assure we are communicating effectively should be a good first step.

It will be interesting to discuss this paper with Dr. Makary if he has the time.


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