Preventable medical errors kill as many as 180,000 Americans every year–more than highway accidents, breast cancer or AIDS, yet until recently such mistakes have been among health care’s darkest secrets.
Douglas Kamerow is a key senior government official trying to do something about both problems. A family physician with training in epidemiology, Kamerow directs the Center for Practice and Technology Assessment of the Agency for Healthcare Research and Quality in Rockville, Md., whose mission is to improve care with “evidence-based medicine,” jargon for finding the facts about what works best.
Q: President Clinton last week announced an ambitious plan to cut the mistakes in half within five years and “to replace a culture of silence with a culture of safety.” First, let’s define medical errors.
A: People hear about the egregious ones–the wrong leg is amputated, or surgeon operates on the wrong side of the brain–but there’s a lot more to it, and it’s subtle. Doctors and hospitals spend a great deal of time trying to avoid mistakes, but they still crop up because human beings make mistakes and the medical system is highly complex. Any medical intention that isn’t completed the way the doctor intended is a medical error. Sometimes there are adverse effects that no one could have predicted. But too often they occur because someone got the wrong drugs or the wrong dosage or is allergic to something and didn’t tell anyone.
Q: Twenty states require some form of reporting of serious mistakes, but the rest don’t. Consequently, the estimates of the problem are all over the map, aren’t they?
A: The numbers vary according to studies. The Institute of Medicine (part of the government’s National Academy of Sciences) recently calculated that as many as 98,000 people are injured or even killed because of mistakes. Other studies put the figure as high as 180,000. That’s a shocking number, and these are just estimates, but they’re probably true. In fact, because they looked mainly at hospital systems, it may even be more than that.
Q: Can you sum up the problem areas?
A: There are several areas where quality is falling short–underuse, overuse, misuse and variation in use of health-care services. For instance, the failure to provide a needed service can lead to additional complications, higher costs and premature deaths. One study of heart attack patients found that nearly 80 percent did not receive lifesaving beta-blocker treatment, leading to as many as 18,000 unnecessary deaths each year. A study of managed-care plans found that 60 percent of diabetics aged 31 and older had not received a recommended eye exam the previous year. The same survey reported that 30 percent of women between ages of 52 and 69 had not had a mammogram in the previous two years and 30 percent of women age 21 to 64 had not had a Pap smear in the previous 3 years, despite the fact that early screening leads to reduced mortality.
Q: And overuse?
A: Half the patients diagnosed with a common cold are prescribed antibiotics. They don’t work against viruses, and the flu is caused by a virus, but that leads to antibiotic resistance and as much as $7.5 billion in excess costs. Another study found that 16 percent of the hysterectomies performed are unnecessary.
Misuse refers to errors in health-care delivery that lead to missed or delayed diagnoses, and unnecessary injuries and deaths. A study of hospitals in New York state found that 1 in 25 patients was injured by the care received and deaths occurred in 13.6 percent of those cases. Negligence was blamed for 27.6 percent of the injuries and 51.3 percent of the deaths.
Q: Drug complications have been found to represent at least 19 percent of all adverse events, nearly half of which could have been prevented, and 30 percent of the patients with drug-related injuries die. What gives?
A: Any complex system–and a hospital certainly is one–is going to have scores of tasks associated with many things. Perhaps hundreds of things will go on with just one patient during the day.
The answer lies not in finding people who make a mistake and punishing them but in creating systems that don’t allow those mistakes to happen. We need systems in which the default mode–what normally happens–is going to be the right thing.
The airline industry did this over many years. They did it by carefully reviewing the mistakes and creating systems that made it virtually impossible for mistakes to happen–things like checklists and redundant systems. These kinds of systems can be implemented in health-care settings as well.
Q: You have several publications that are available to the public by phone at 800-358-9295, or at your Web site, www.ahrq.gov. What can people do to help lower the chances of suffering an adverse event?
A: The single most important thing is to be involved in your own health care. Research shows that patients who do this tend to get better results. What conditions do you have? What drugs are you taking? What are you being treated for? You should know.
Make sure the doctor knows about any allergies you have, or previously adverse reactions to medications. In fact, make sure all of your doctors know about everything you are taking, including over-the-counter medicines and dietary supplements such as vitamins and herbs.
When your doctor writes you a prescription, make sure you can read it. If you can’t read your doctor’s handwriting, what makes you so sure the pharmacist can? And ask for information about your medicines in terms you can understand, both when they are prescribed and when you receive them. What is the medicine for? How are you supposed to take it, and for how long? What side effects are likely and what do you do if they occur? Is the medicine safe to take with other medicines or dietary supplements you may be taking? What food, drink or activities should you avoid while taking this medicine?
Q: Pharmacies can be gold mines of information. What should you ask?
A: When you pick up your medicine from the pharmacy, ask if it’s what your doctor prescribed. A study found that 88 percent of medicine errors involved the wrong drug or the wrong dose. Many drugs sound alike but are completely different. Also, medicine labels can be confusing. For example, does `four doses daily’ mean one dose every 6 hours around the clock or just regular waking hours?
And learn the best way to measure liquid medicine. Many people use household teaspoons, which often do not hold a true teaspoon of liquid. Special devices, like marked syringes, can be more accurate.
Q: What about hospital stays?
A: Choose a hospital that does the procedure or surgery you need very often. Research shows the outcomes are better that way, and you are entitled to ask your doctor about it.
If you’re in the hospital, consider asking all health-care workers who have direct contact with you whether they have washed their hands. Perhaps you even can put a small sign above your bed. A recent study found that when patients checked whether health-care workers washed their hands, the workers did so more often and used more soap. That’s an important way to prevent the spread of infections in hospitals.
When you’re being discharged, make sure what you understand what you’re supposed to do next. Research shows that doctors think their patients understand more about the treatment plans than they really do.
Q: Is there any way to protect yourself in surgery?
A: Make sure that you, your doctor and your surgeon are clear about exactly what will be done. When you’re wheeled into the operating room, it never hurts to ask: What’s going to happen?
Doing surgery on the wrong site–for example, operating on the left knee instead of right–is incredibly rare. But even once is too often. The American Academy of Orthopaedic Surgeons urges its members to sign their initials directly (on) the site to be operated on before the operation.
Q: The government is requesting that all states develop some sort of reporting system for medical mistakes. How can we take individual cases and learn from them?
A: Medical care needs to be individualized, but the evidence needs to be nationalized. What works best? What doesn’t work? What should we watch out for? We should be able to learn from the evidence and not have to reinvent the wheel. This kind of information can close the gap between what we know and what we do. Quality can only improve that way.
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An edited transcript.
