Doctors used to routinely do more harm than good, and even today deadly medical errors remain a problem. But experts are moving to improve the situation.
By JUDY SIEGEL-ITZKOVICHdoctors 224.88(photo credit: )
The next time you go to your health fund clinic or hospital, think how fortunate you are: Just a century ago, around 1910, was the first time in history that a person had a better than 50-50 chance of benefiting from seeing a doctor. Physicians either had no effective treatment, or the treatment given actually caused harm.
Since then, the amount and quality of medical knowledge has multiplied thousands of times, and the rate of outright mistakes has greatly declined. There are protocols to guide medical staffers, and in many hospitals electronic equipment warns if a patient is getting the wrong drug. But even so, it's estimated that every year 180,000 patients in the US - and 2,000 in Israel - die or are seriously harmed as a result of medical error. That's equivalent to a Boeing 787 crashing every day. But no one knows exactly what the toll is because medical errors are seldom reported or investigated.
Hippocrates, the Greek "father of physicians," stated in his dictum for doctors: "First, Do No Harm"; only afterwards should a doctor consider how to make a patient better. Amputation of a healthy leg, infusion of the wrong type of blood, injection of a drug 10 times more concentrated than required, an elderly patient falling out of his hospital bed - these are only a few of the endless things that can go wrong.
Until the mid-1990s, very few medical facilities were willing to discuss errors. That was the norm until Betsy Lehman, a 39-year-old mother of two - who was, ironically, health and consumer affairs reporter of the Boston Globe and had Israeli relatives - was hospitalized in the city's Dana Farber Medical Center for treatment of curable cancer. She was mistakenly given the wrong dose of a chemotherapy drug, which killed her.
The case led a University of Chicago researcher and writer, Prof. Richard Cook, to publish and speak about preventing errors in complicated systems. A charismatic speaker, Cook appeared at an October 2000 workshop at Hadassah University Medical Center in Jerusalem, where he discussed his theory that professional errors are like Swiss cheese. "In an ideal world, each defensive layer would be intact," he said. "In reality, however, errors are more like slices of Swiss cheese, having many holes - though unlike in the cheese, these holes are continually opening, shutting and shifting their location. The presence of holes in any one 'slice' does not normally cause a bad outcome; this can happen only when the holes in many layers momentarily line up, bringing hazards into damaging contact with the victims. No two accidents have exactly the same positioning of holes."
COOK WAS not in Jerusalem to attend another workshop, "Patient Safety Collaboration between Israeli and US Hospitals" held earlier this month at the Hadassah University Medical Center on Mount Scopus. Prof. Zvi Stern, director-general of the Mount Scopus hospital, was the host, along with Dr. Shmuel Reznikovich, director of administration at Netanya Geriatric Medical Center. Foreign participants included executives of the VHA hospital system in the US (formerly in charge of the US Veterans Administration hospitals) and Rulon Stacey, president and CEO of the Poudre Valley Health System based in Colorado.
Cook's spirit was there, however, as the Swiss cheese analogy was mentioned, and senior Hadassah anesthesiologist Prof. Yoel Donchin, who had invited Cook to the 2000 workshop for his first visit to Israel, was one of the speakers.
Donchin presented a mostly historical lecture about doctors who believed in the prevention of disease and medical errors. A 15th-century Italian named Bernardino Ramazzini, he noted, was the first expert on the causes of occupational diseases and errors. "He even described carpal tunnel syndrome [inflammation of the tendons in the wrist due to repeated movement like clicking a computer mouse] and said it was preferable to prevent diseases rather than to treat them. Hungarian-born, 19th-century physician Dr. Ignaz Semmelweis, considered the father of medical staffers' handwashing, was called "the savior of mothers" for preventing many deaths from "childbed fever." The safety movement in the US started with anesthesia; the death rate from it during surgery was one per 3,000 patients, but today it is closer to one per million. "We didn't change only anesthesia drugs," stated the Hadassah anesthesiologist. "We changed our attitude."
DONCHIN IS currently on sabbatical at the Technion Rappaport Medical Faculty's center for safety at work and looking into improving ergonomics and preventing errors in intensive-care units. "Some claim that collecting data on errors reduces them, but this is less effective than investing in the improvement of human factors." Donchin reduced errors at Hadassah operating rooms by hanging easy-to-read posters on the walls; doctors and nurses read them to get a mental model of what they have to do.
Prof. (emeritus) Omri Lernau, formerly a Jerusalem surgeon who is now head of surgical services at Maccabi Health Services and a consultant to the Inbal Insurance Company, suggested that teamwork between senior physicians and residents, in which each knows his responsibilities, is vital in reducing errors. "Medical treatment is delivered by interdisciplinary and intradisciplinary teams. There are experts and novices. During after-hour shifts, the inexperienced medical resident is in the hospital and the expert is at home, available by phone. A study of 240 malpractice claims showed that 70% were due to breakdowns in teamwork and communications."
Lernau said the expert has overall responsibility and must be available at all times. He has to report to the hospital within a predefined period, know the patients, and actively seek updates on their status. Meanwhile, the resident on duty must remain in the hospital and report to the senior doctor on call about new patients and developments.
"But there are still unsolved basic problems because the resident on call has to realize when he needs to call for help, and the expert on call depends on the resident. The system usually works, but sometimes it doesn't. It is best for an unwritten contract between them in which the expert insists the resident call him at a set hour to report on all patients, or every time a patient with a specific condition is admitted," Lernau said.
An extremely important and effective way to reduce errors is for doctors not to practice new procedures or techniques on humans. Dr. Amitai Ziv, a former pilot in the Israel Air Force who specialized in pediatrics, is today deputy director-general at Sheba Medical Center and founder and director of MSR, one of the most advanced medical simulation centers in the world. He was introduced to simulation as a pilot, but when he switched over to medicine, Ziv faced culture shock because of the lack of it. "Medical training is different, but both it and flying are high risk and hi-tech industries. In both, there must be low tolerance for errors, and simulation is an important safety tool," said Ziv. "It's a safe environment that gives staff experience, feedback and debriefing; it is reproducible, standardized and objective. Medical teams can watch themselves on video; insurance companies and patients don't allow videotaping of actual surgery."
MSR, a non-profit fee-for-service center that uses hi-tech patient simulators, live actors and other techniques, offers easy-to-measure competence in both technical and non-technical skills and behavior in a broad variety of medical, dental, nursing and other fields. It is used for screening, licensing and certification as well as training.
"MSR is now being used to deal with child, domestic and elder abuse and improved functioning of pharmacies. We have introduced simulation for doctors' delivery of bad news, including a patient's death, and are using actors to learn to apologize for mishaps," added Ziv.
Marly Christenson, a representative of Providence Health and Services - the sixth largest health maintenance organization in the US with 27 hospitals - said minimizing errors can be promoted by making a "culture of safety" that is expected of all staffers. "Our hospitals promote better teamwork and communications, a rapid response to prevent heart attacks and other crises in hospital, preventing infections and adverse drug events," she said. "It is done during the rounds, visits to units and lectures to staff, and with incentives, medication bar coding, checklists, safety briefings and debriefings.
THE 125 university-affiliated, public medical centers in the US have to invest even more in patient safety, said Prof. Steven Simon. of Harvard Medical School, because they include teaching hospitals with high staff turnover. Safety officers have to transmit their message constantly. "Blaming people doesn't solve anything" he insisted. "You have to improve medical systems for better collection of data, analysis and testing of interventions and then implement reforms."
But as independence is prized in research institutions, there is lower regard for and higher resistance to systems thinking and standardization. Yet pressure is coming from outside, as Medicare is starting to refuse to cover treatments when a surgeon operates on the wrong limb, when surgical equipment is left inside a patient, or when there are preventible infections.
The participants in the two-day collaborative workshop went back to their work in the US and Israel, but contact will continue, as the workshop was the first of its kind to link them and their hospitals to reduce errors. It is also hoped that hospitals in Israel, the PA and in Arab countries will join in.
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