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The Blame Game: How Mistakes Are Handled In The Modern Health Care System

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"One consequence of the cases of health care workers becoming infected in Texas, after treating an infected man who had traveled from Africa, is that hospitals in every U.S. city are more alert to the high price of making a preventable mistake. Sound Medicine contributor Lauren Silverman explores how that is playing out."

Silverman: Accidents happen, and hospitals aren’t immune.

Dr. Albert Wu: They are busy chaotic places, and when you do get information there’s a lot of it!

Silverman: Dr. Albert Wu is a professor of health policy and management at Johns Hopkins. Not long ago, Wu made a mistake. He prescribed an antibiotic that a patient was allergic to.

Dr. Wu: The information was written in the chart but I did not have that immediately available to me.

Silverman: She didn’t die, but she did get a serious rash. While no one likes to hear about mistakes in medicine, they happen all the time. In one study looking at malpractice suits at eight hospitals, researchers found nearly nine teamwork errors in each patient case and said half of the resulting harm could have been avoided.

Silverman: Why? Humans, circumstances, and systems.

Dr. Brian Goldman: Good, intelligent, well-trained, ethically grounded medical professionals are making mistakes every day. They just don’t know it because we’re not curious.

Silverman: Dr Brian Goldman is curious. He’s an ER physician at Mount Sinai Hospital in Toronto and a medical journalist. Goldman says in medicine, the knee jerk reaction is to find someone to blame. That means nothing is wrong with the system.

Silverman: Just look at what happened with Texas Health Presbyterian in Dallas.

Goldman: So in the first case it was a nurse who didn’t transmit the information, then the electronic health record, no it’s not, now it’s a physician, and I understand that the root causes of medical errors, is there are usually a litany of factors that contributed.

Silverman: Here’s where Goldman points to the Swiss cheese model of mistakes. At each decision point, from the first encounter by the nurse, to the last note scribbled by a physician, each small decision is like a slice of Swiss cheese – there may be holes, but a tiny gap in flavor won’t be a problem.
When all those holes line up, catastrophe.

Goldman: And the point there is there are many places along the line when a catastrophe could be averted. And it can be averted if you have multiple checks and balances and if you have an open system in the culture who allows anybody to say, you know what, I wonder if this guy’s got Ebola.

Silverman: Electronic health records can help with checks and balances -- for example, if a nurse enters the words nausea and temperature in an electronic note, a prompt about recent travel history might pop up. Hospitals across the country are betting technology like electronic medical records will keep patients safe. This week, Dr. Kyle Janek – who runs Texas Health and Human Services shared a sober reminder.

Dr. Kyle Janek: We can automate a lot of things, we can make computers pop up certain notices. But at the end of the day, the backbone of this system relies on human beings.

Goldman: Probably one of the worst mistakes I’ve made as a physician was sending a patient home when I was a trainee.

Silverman: Again, Brian Goldman in Toronto.

Goldman: “In this case it was a patient who had congestive heart failure and then I sent her home…she collapsed several hours later, was sent to eh hospital and she passed away.”

Silverman: It was horrible for her family, he says, and horrible for him. Dr. Wu at Johns Hopkins says with medical mistakes come multiple victims.

Dr. Wu: A second victim is a health care worker who is also traumatized by a bad outcome that a patient experiences.

Silverman: Goldman certainly felt that way.

Goldman: That unhealthy shame that springs from this notion that’s out there in the culture of medicine that physicians never make mistakes. If you’re never supposed to make a mistake. Then your first attitude is to be shocked and appalled when a mistake is evident.

Silverman: Instead, Goldman says it’s time to get curious. Don't run from the mistake, run toward it.

  • Sound Medicine contributor Lauren Silverman is a reporter for KERA News. You can follow her on Twitter at @lsilverwoman.