[SSRI-Research] Curing medical mistakes--Change the Culture of Care_ Robert Wach

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Fri, 1 Sep 2006 17:07:11 -0700 (PDT)

[sSRI-Research] Curing medical mistakes--Change the Culture

of Care_ Robert Wachter, MD

 

 

 

 

ALLIANCE FOR HUMAN RESEARCH PROTECTION (AHRP)

Promoting Openness, Full Disclosure, and Accountability

http://www.ahrp. org

 

FYI

 

Dr. Robert Wachter, author of The Truth Behind America's Terrifying

Epidemic of Medical Mistakes, provides an incisive blueprint for

changing the culture in medicine. His starting point is the

unexplained death of children

following surgery at Stony Brook University Hospital, L.I.

 

Noting how different medicine is today from the iconic Marcus Welby,

MD, was practicing (on television, 1969 to 1976), Dr. Wachter says:

For one thing " it's been estimated the average physician in Dr.

Welby's era had to master the use of approximately 10 medicines.

Today, that number is close to 500! "

 

The fact is, most prescribing doctors do not know the hazardous effects of

the drugs they prescribe. Most doctors rely on the drug myths delivered by

sales reps and reinforced by colleagues whose reputation as " opinion

leaders " is measured by their income from pharmaceutical companies.

 

The surgical arena is not much better:

" If you could walk into an intensive care unit or observe a modern heart

surgery, you'd quickly appreciate that increasingly what determines

whether

a patient lives or dies is not whether the doctor is as smart as current

television's Dr. Gregory House, but rather whether there is a functioning

computer system (which not only prevents handwriting errors but

suggests the

right medicine at the right time and reminds the doctor a certain two

drugs

shouldn't be given together). And whether there are policies and

procedures

(such as strict hand-washing guidelines, and a protocol for the surgeon to

sign the surgical site to prevent operating on the wrong leg) that are

thoughtfully developed and rigorously enforced. And whether the doctors,

nurses, technicians and hospital administrators work together as a team. "

 

Imagine, hospitals getting licenses without minimal basic functioning

computer systems; imagine doctors requiring " strict hand-washing

guidelines; " imagine surgeons operating without verifying that they are

performing the surgery on the right organ!

 

" This final issue may be the most important of all. At my hospital (UCSF

Medical Center) and several other centers around the United States, we

have

enlisted the help of commercial airline pilots to teach us how to

communicate better, how to dampen down hierarchies (so that a young nurse

feels comfortable questioning a senior doctor when something seems awry),

and how to debrief participants after an operation, just as crew

members are

debriefed after a flight. "

 

Yes, and the FDA should also turn to pilots to help develop a meaningful

drug safety evaluation protocol.

 

Contact: Vera Hassner Sharav

212-595-8974

veracare (AT) ahrp (DOT) org

 

http://www.newsday. com/news/ health/ny- opwac274866145au

g27,0,5285311. story?co

ll=ny-health- print

 

Newsday August 27, 2006

 

Curing medical mistakes

The answer to any Stony Brook hospital problems likely rests with the

culture of care, not a few 'bad apples'

 

BY ROBERT M. WACHTER

 

Robert M. Wachter, M.D., is associate chairman of medicine at the

University

of California, San Francisco, and co-author of " Internal Bleeding: The

Truth

Behind America's Terrifying Epidemic of Medical Mistakes. "

 

The recent reports about unexpected deaths of children after cardiac

surgery

at Stony Brook University Hospital are tragic, and they raise important

questions about how we measure and safeguard the quality of care. Although

we will have to let the investigation take its course to find out whether

medical errors or violations of care standards led to these deaths, the

events at Stony Brook help frame the challenges we face in ensuring

patients' safety.

 

This is an important issue. A 1999 report by the Institute of

Medicine, the

medical branch of the National Academy of Sciences, estimated that

44,000 to

98,000 Americans die each year because of medical errors, the

equivalent of

a jumbo jet crashing every day. Research from the Rand Corp. think

tank has

demonstrated that medical care comports with recommended guidelines

slightly

more than half the time in the United States. And a recent report also by

the Institute of Medicine found that, on average, a hospital patient

experiences one medication error - not necessarily severe - every

single day

he or she is in the hospital.

 

How can this be? The answer, as we've come to learn, is not completely

intuitive. Whenever we hear about bad things happening to patients, we

naturally try to point fingers - to find (and then to sue and pull the

license from) the " bad doctor " or " bad nurse " responsible for the problem.

 

And there are some bad health care providers - people who are poorly

trained, don't keep up with advances in their field or abuse drugs or

alcohol - who shouldn't be caring for patients. We should do more to

identify these individuals and get them the help they need to improve or

make sure they never hurt another patient.

 

But think about your own doctor, and the nurses you've met. Is it possible

they are all lazy, poorly trained and careless? Of course not.

Understanding

this helps make the point that the quality and safety of health care

is not

just about the quality of individual practitioners, it is also about the

systems of care in which we health care professionals work and in

which you

receive your care.

 

The " system-ness " of care is a relatively new phenomenon. When Marcus

Welby,

MD, was practicing (on television, 1969 to 1976), it may well have been

possible for a well-trained, careful and competent doctor to prevent most

medical errors. After all, it's been estimated the average physician in

Welby's era had to master the use of approximately 10 medicines.

Today, that

number is close to 500!

 

If you could walk into an intensive care unit or observe a modern heart

surgery, you'd quickly appreciate that increasingly what determines

whether

a patient lives or dies is not whether the doctor is as smart as current

television's Dr. Gregory House, but rather whether there is a functioning

computer system (which not only prevents handwriting errors but

suggests the

right medicine at the right time and reminds the doctor a certain two

drugs

shouldn't be given together). And whether there are policies and

procedures

(such as strict hand-washing guidelines, and a protocol for the surgeon to

sign the surgical site to prevent operating on the wrong leg) that are

thoughtfully developed and rigorously enforced. And whether the doctors,

nurses, technicians and hospital administrators work together as a team.

 

This final issue may be the most important of all. At my hospital (UCSF

Medical Center) and several other centers around the United States, we

have

enlisted the help of commercial airline pilots to teach us how to

communicate better, how to dampen down hierarchies (so that a young nurse

feels comfortable questioning a senior doctor when something seems awry),

and how to debrief participants after an operation, just as crew

members are

debriefed after a flight.

 

This kind of team training does not come naturally to most doctors. But it

did not come naturally to pilots either when it was introduced 20

years ago.

After all, the old pilot personality (remember " The Right Stuff " ) was as

macho as any surgeon's. In fact, many pilots dismissed early teamwork

training programs as " charm school. "

 

It was only after several horrible plane crashes (including the 1977

collision of two 747s in the Canary Islands that killed nearly 600 people)

that aviation learned the price to be paid when one member of a

cockpit crew

suspected something might be terribly wrong but didn't feel comfortable

challenging the boss' judgment.

 

Since that time, aviation has required all its flight personnel to

participate in teamwork and simulator training to create a more

collaborative environment, with better communication among all the

workers.

Judging by the breathtaking decrease in commercial aviation accidents over

the past generation, these efforts to create a safer culture have worked

astonishingly well.

 

As we try to learn how to improve medical systems and culture - drawing on

lessons from other industries where appropriate - it is critical to

remember

that caring for a sick patient is, of course, far more complex than

flying a

jumbo jet. It's equally important we never forget we are not working with

machines, but caring for sick human beings. Even as we embrace " systems

thinking " to improve quality and make our care more reliable and less

glitchy, medicine is, and will always be, a uniquely human undertaking.

 

It is too early to judge whether the problems at Stony Brook Hospital are

widespread and systemic or represent an awful statistical fluke. At this

point, the decision to suspend pediatric heart surgeries while this is

sorted out seems prudent. If recent history is a predictor, the answer to

any problems that may be uncovered at Stony Brook are more likely to be

found in trying to improve the systems of care and the culture of safety

than in trying to find and punish one or two bad apples.

 

Today's medicine is so complicated that trying to mint the flawless doctor

or nurse is a fool's errand. Instead, we need to create a system that

anticipates human beings - even very well trained, hardworking and

compassionate ones - will blow it from time to time, and that catches

these

errors before they cause more tragedies.

 

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