THCB

An Error about Mistakes

Paul Levy 1There are few neurologists I admire more than Martin Samuels, chief of service at Brigham and Women’s Hospital in Boston.  So it truly pains me to see him engaging in a convoluted approach to the issue of mistakes.  Read the whole thing and then come back and see what you think about the excerpts I’ve chosen:

“The current medical culture is obsessed with perfect replication and avoidance of error. This stemmed from the 1999 alarmist report of the National Academy of Medicine, entitled “To Err is Human,” in which the absurd conclusion was propagated that more patients died from medical errors than from breast cancer, heart disease and stroke combined; now updated by The National Academy of Medicine’s (formerly the IOM) new white paper on the epidemic of diagnostic error.”

No, the obsession, if there is an obsession, is not about perfect replication and avoidance of error.  The focus is on determining the causes of preventable harm and applying the scientific method to design experiments to obviate the causes.  The plan is, to the extent practicable, implement strategies to help avoid such harm.

[T]here is actually no convincing evidence that studying these mistakes and using various contrivances to focus on them, reduces their frequency whatsoever.

Yes, there is convincing evidence (from Peter Pronovost’s work on central line protocols, for example) that the frequency of errors that lead to preventable harm can be dramatically, and sustainably, reduced.

For example, there is absolutely no reason to believe that a comprehensive medical record will reduce the frequency of cognitive errors, whereas it is evident that efforts to populate this type of record can remove the doctor’s focus from the patient and place it on the device.

Well, here’s one place we agree! EHRs might actually increase the chance of cognitive errors. But why would you pick that one example, Martin?

We all try to avoid errors but none of us will succeed. This is fortunate as errors are the only road to progress. Focusing on the evil of errors takes our attention away from the real enemy, which is illness. We should relax and enjoy the fact that we are lucky enough to be doctors.

There are errors that lead to progress and there are errors that lead to death and other harm. The flaw in Martin’s article is not so much what he says, as the extrapolation he makes from what he says.  A friend sent me a note summarizing the case nicely:

While I agree that we’ll probably never achieve zero errors in healthcare for a number of valid reasons, there is ample evidence that a systematic approach based on the scientific method can significantly reduce harm to patients.  Yet, there is no reference to the great work done by so many of his colleagues, e.g., Peter Pronovost, Lucian Leape, Donald Berwick, John Toussaint, Robert Wachter and Gary Kaplan, just to name a few.  Nor is there any empathy toward the patient and the impact of avoidable harm on his or her life.

Paul Levy is the former CEO of BIDMC and blogs at Not Running a Hospital, where an earlier version of this post appeared. 

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pschilstraBobbyGvegasMichael_PainterPaulflevyNortin M Hadler Recent comment authors
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pschilstra
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pschilstra

For full disclosure, I am the friend who Paul quotes toward the end of his blog. Allow me to offer a, hopefully, balanced and respectful perspective to this discussion as the father of a two-time leukemia survivor and as one who worked in healthcare for over thirty years. For your information, my background is in industrial engineering, operations research and IT and I apologize upfront for any resulting biases that may cloud my thinking. I am humbly reminded by Dr. William Osler comment that “No human being is constituted to know the truth, the whole truth, and nothing but the… Read more »

Michael_Painter
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Being a physician is an awesome responsibility and great gift. The relentless focus of that professional should be on the health and well-being of her patients—first, last and always. It is shocking to read the recent post by Samuels, a physician leader who apparently doesn’t get that basic point. I only wish that “[t]he current medical culture is obsessed with perfect replication and avoidance of error.” If only. I do agree with this statement in the post: “We all try to avoid errors but none of us will succeed.” That is all too true. Patients need to understand that fact… Read more »

BobbyGvegas
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I do agree with this statement in the post: “We all try to avoid errors but none of us will succeed.” That is all too true. Patients need to understand that fact too. We all need to work together to minimize errors that hurt, maim and kill.
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David Marx — “Just Culture”

http://regionalextensioncenter.blogspot.com/2014/06/continuing-on-three-legged-stool-riff.html

Paulflevy
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Paulflevy

Dr. Hadler, I am not talking about “nuts and bolts.” I am talking about preventable harm that is caused to patients. I am not talking about judgment calls where MDs used the best of their knowledge and experience and nonetheless had bad outcomes. I am talking about the manner in which work is organized in many hospitals that permits errors to occur in the normal course of care–medication errors, unwarranted infections, high rates of ventilator associated pneumonia–to mention a few. Several places in the world have been able to apply the scientific method in designing experiments and developing approaches to… Read more »

Simon Nath
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I crossed paths with Dr Samuels a long time ago when we were both speakers at a CME course held by the American Geriatrics Society and the American College of Physicians. I still remember his talk for its content and for its clinical perspective. His post on THCB is similarly worthy. Mr. Levy doesn’t get the point. Mr. Levy is talking about nuts-and-bolts; Dr Samuels is talking about the challenges of doing well by our patients. Errors in process, obvious errors such as giving the wrong dose or leaving a sponge in the abdomen, all of which are incontrovertibly errors,… Read more »

Barry Nathanson
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Barry Nathanson

As an Internist/hospitalist/intensivist I know well the errors, uncertainties and self doubts that come with patient care. I also know ways to reduce those doubts. One example is by complying with best practices. Two weeks ago I followed up on one of my patients who’d been transfered post-arrest to our MICU. I watched my senior colleague insert a RIJ CVC without ultrasound and without a sterile gown on himself or a sterile sheet on the patient! (Yes, I’ve since dealt with that problem.) But here we are, 15 years or so after the landmark IOM publication and many years after… Read more »

RogueRad
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In the realm of diagnosis, that is my realm, an error has often implied a 100 % sensitivity and a 100 % specificity. This is aspirational.