Fatal errors

Fatal errors

November 22, 2009 07:17

One would think that as scribbled medical files have been replaced by computerized records, and medical staffers can easily consult with drug databases and colleagues worldwide, the number of medical errors and cases of malpractice in hospitals and clinics would have been significantly reduced. Nevertheless, they continue to occur, often in other forms. Risk-management experts say errors cannot be eliminated completely, but briefings of surgical teams before every operation, packaging drugs to differentiate among them, reviews of medical data entered into computers, backup, monitoring and other techniques could do a lot to bring down the number of incidents. Just as importantly, shifts made inordinately long due to the shortage of physicians and nurses must be shortened so that errors do not result solely from fatigue. Deaths due to medical error are difficult to identify. US estimates range from 44,000 to 98,000 a year. It is certainly riskier than flying. HOW TO reduce medical errors and malpractice was the subject of a recent full-day conference held in the Knesset auditorium, organized by the Ariel University Center in Samaria and initiated by Kadima MK and trained gynecologist and lawyer Rachel Adato. Knesset Speaker Reuven Rivlin said that while most medical treatment ends to the satisfaction of both carer and patient, the public hears of medical errors from the media and tends to become nervous about being hospitalized. In fact, a Geocartography poll conducted for the conference found that almost 40 percent of a representative sample thought medical negligence was quite common, and that staffers whose carelessness caused harm rarely got punished. Two-thirds of people in the sample believed their health was liable to be harmed due to nosocomial (in-hospital) infections or other problems, not including the condition for which they were admitted. "We put our health and lives in the hands of medical staffers. They are very devoted, but also pressed by work," Rivlin said. "One needs to strike a balance between staffers' awareness of preventing medical errors, and regulation by the Health Ministry." DR. ZE'EV AHARONSON, head of the medical division of Kupat Holim Meuhedet (the country's third-largest health fund), noted that "there can be an error in diagnosis, imaging or lab results, drug dosage or identification, surgery or medical equipment. X-rays can be sent to the wrong file." In addition, it is harder today to identify hospital patients than in the past. "Before, doctors knew their patients. Since paper medical files were replaced, everything has been computerized," said Aharonson. "You may have several patients with the same name. Some hospitals include a photo of each patient in their databases to reduce errors. We are the in-between generation, in which computers do not prevent all errors. Hospital staffers must follow up test results and alter the computerized records exactly. If there are two patients with the same surname, the wrong bar code for tests could be entered into files." He advised patients to ask questions, annually bring a list or bag of drugs taken for the doctor to assess, make sure to get printed results after tests, understand what an operation involves and appoint someone to make decisions on their behalf in case they are unable to do so. Patients should also feel free to get a second opinion before any major procedure, he said. THE HEALTH FUND'S top physician noted that in recent years, many developed countries have recognized the need to grant immunity to medical personnel who report error. "If you immediately punish for errors, you won't get any reports, and the same type of errors will continue to happen," said Aharonson. "One error is not involved. Health systems must identify the cascade of errors that lead to a major safety problem." The Health Ministry's new director-general, Dr. Eitan Hai-Am, strongly endorsed the no-fault policy for honest mistakes. "I think that at the end, we should adopt Denmark's practice, in which everyone has to report errors, and an impartial state body investigates and makes sure there is change. It will not release identifying information. Over 89 percent of errors are due to faults in the system," he said. But surprisingly, Deputy Health Minister Ya'acov Litzman, who arrived at the end and did not hear his directorgeneral's lecture, said later that he opposed a no-fault system and preferred transparency. MORE PEOPLE die of inappropriate or conflicting medications in the US than of diseases, said Dr. Arik Kahana, director of the risk management unit at the private Assuta Medical Centers. "Errors are the biggest cause of death there except for heart disease and cancer." He added that doctors' and nurses' communications with patients and their families were very important. "All patients insist on the newest technology, want to decide who does it and where, want it now, prefer not to pay for it from their pockets and want it to succeed. Medicine is an autonomous profession; physicians can make decisions alone, even when convention is different - but they must keep records and explain their decisions to help protect themselves against malpractice suits. Nobody goes to work planning to make an error." There are unforgivable errors such as operating on the wrong part of the body, administering the wrong drugs or giving the wrong dosage, he said. Ink markers are often used before an operation so surgeons will not err, but if the same marker is used on many patients, it can spread germs. "Hospitals and health funds have an inherent interest in preventing errors," concluded Kahana, "because of the short-and long-term costs of risk, the cost of investigation, the harm to their reputations, legal costs and rising malpractice insurance premiums." DISEASES ARE more complicated than ever, said Dr. Shoshi Goldberg, director of nursing at Sheba Medical Center, the country's largest hospital. "There's a great deal of knowhow and better environments and equipment in Israeli hospitals. But despite this, we sometimes risk the health of patients and even ourselves," said Goldberg. "There should be more interdisciplinary teams that minimize the number of errors. A patient could be moved from one department to another, but his injection pump may not move with him. The drug protocol in the next department could be different, endangering the patient. Bottles that look the same but hold different drugs can easily cause confusion. If a nurse gives the wrong dosage, she is responsible but not to blame; the nurse is at the front, but the hospital is to blame. Hospitals have to create a culture of reporting errors, but staffers won't do it if it puts a colleague in danger." THERE IS a higher risk for error when people are unfamiliar with the tasks and lack time and when there is inadequate checking, said Prof. Yossi Mekori, dean of Tel Aviv University's Sackler Medical Faculty. Medical students at the school are now exposed to many lectures on avoiding errors. "Fatigue, stress, hunger, illness, language and cultural factors are common causes. We do simulation exercises, and there are small group discussions based on observed errors and case studies. We have studied how other industries such as aviation work to prevent mistakes," the dean said. "Less energy must be expended on blame and more on finding how an error occurred. Students are required to discuss errors they observed in hospitals. We try to help students become leaders in patient safety," he went on. "This is a positive cultural shift, although it may create some tension between a student and a physician. In the past, when a medical student saw that a senior surgeon failed to complete a pre-operation checklist, he had to shut up because the surgeon was 'always right.' Today, it is permissible and even demanded to speak up. We try to teach students to be active." Some 4,500 civilian malpractice suits are filed here in an average year, said Prof. Chaim Hershko, the senior ELECTRONIC record keeping was supposed to make errors in prescription and dosage a thing of the past. That's not the way it worked out. EXPLAINING THE role of the media, which are generally very aggressive in reporting medical errors and malpractice, ministry deputy directorgeneral for information Ya'ir Amikam deplored sensational headlines such as the one that covered most of the front page of Yediot Aharonot the day before the conference: "31 years old, healthy, dead of swine flu." But understanding that publishers' drive to make money may conflict with their better judgement makes his job a bit less frustrating, he said. Cabinet ministers are acutely aware of alleged scandals reported by the media, and usually demand immediate investigations and explanations from their underlings. "The media and the health system thus do not speak the same language, due to the different deadlines and aims," Amikam said. "Increasing transparency to the media can bring about a better relationship between government and the media, and can even increase safety." ministry official who is the address for patients' complaints against medical personnel. "But my office receives only about 20 complaints a week that could lead to sanctions. Most cases don't come to me because we don't hand out money. People who want money go straight to the courts." Hershko informs the institution that employs the person against whom a complaint is filed. Then, if necessary, a committee of at least two experts prepares a report that examines both individual and system problems. "It's legitimate to punish a doctor who did wrong, but statistics show that out of 100 malpractice cases, 5% of the physicians are responsible for at least half," he said. "These repeaters must be identified so action can be taken and future mistakes prevented." Many errors, he stressed, "are made by good doctors who make the wrong decisions, are not familiar with the latest medical literature, choose the wrong technique or carry it out badly. They can be better trained, and preventing errors in this way must be institutionalized. Many errors, said the ministry ombudsman, are due to automatic behavior; if there are two drugs in the same packaging, a tired nurse can get confused in the middle of the night." He advised that "if a genuine error were committed, the medical institution should apologize in a straightforward way, make fair settlement offers, involve the family and carry out a visible institutional effort to avoid similar events in the future. Rare cases of 'bad apples' should be dealt with aggressively." As for patients, if they want to reduce their risk of being victims of errors, they should "be friendly with those who treat them; be selective with their questions so as not to be regarded as a pest, but firm and inquisitive; make sure they are properly identified; and speak up when things go wrong."

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