Archive - Jul 12, 2011

Rethinking Medical Errors

According to a KOMO News report, earlier this year, Kimberly Hiatt took her own life after being under investigation with regards to the death of an infant due to a mathematical miscalculation.

Kaia was being kept alive with the help of a Berlin heart, but she suffered a setback when a nurse in the hospital's intensive care unit gave her 10 times the normal dose of calcium chloride. She died several days later.

In a letter to the Seattle Times, retired anesthesiologist F. Norman Hamilton wrote:

With the case at hand, my first concern is that I am hard-pressed to think of a reason that I would prescribe calcium chloride for an infant when the drug was to be administered by a solo nurse in a nonemergency situation. Second, calcium chloride is a dangerous drug and when used in infants, its dose should be double checked by the pharmacy staff.

The fact that the hospital changed its policies after the death implies that they realized that its policies were inadequate. Despite this, the hospital decided to fire the nurse for an arithmetic error.

In addition, I am at a loss to see how a fine, levied by the state disciplinary authorities, is even a help to the infant’s family, the public or the nursing profession.

If we fire every person in medicine who makes an error, we will soon have no providers. We all make errors.

This story came to mind as I read a few other news stories today. The LA Times ran the story, Baby's death spotlights safety risks linked to computerized systems. It starts:

The medical error that killed Genesis Burkett began with the kind of mistake people often make when filling out electronic forms: A pharmacy technician unwittingly typed the wrong information into a field on a screen.

Because of the mix-up, an automated machine at Advocate Lutheran General Hospital prepared an intravenous solution containing a massive overdose of sodium chloride — more than 60 times the amount ordered by a physician.

The article goes on to say,

The U.S. Food and Drug Administration in December acknowledged getting 370 reports of problems involving health information technology since January 2008, including several dozen patient injuries and deaths, but those numbers are likely to be low because such reports are voluntary

Also noted today was an article in “Off the Charts” in the American Journal of Nursing. “New Medical Residents and Patient Mortality – Does the ‘Nurse Effect’ Lessen the ‘July Effect’?

The article ends with

The Times article notes this caveat about most research on the topic: “Some researchers say looking at surgical residents and outcomes for severely ill patients obscures the effect, since surgical residents are often part of a team and patients with the most serious conditions receive more attention.” I agree, as most of those patients will be under the careful scrutiny of nurses in the early postoperative period or in an ICU.

I don’t think one can realistically evaluate the “July effect” without considering the “nurse effect.”

Is there a theme to all of this? It seems as if in our efforts to place blame and find scapegoats, we often overlook that most activity takes place in a broader context. Accidents are not because of one nurse, one pharmacy technician, one computer system, or one resident. They are the results of systemic failures and in our effort to avoid blame, we fail to look at systemic failures.

Some doctors in the United States are suggesting that we need tort reform to address the cost of malpractice insurance. If we have a limited liability for our failures, that will bring down the costs, they argue. There are lots of problems with this argument. Should the liability for a medical error be less than for an error behind the wheel of an automobile? Or should we limit liability for every kind of mistake? It also fails to address the systemic issues and how we can work to better address systemic issues.

Perhaps a wiser approach is to move towards a no-fault approach to malpractice, similar to how many states have moved to no-fault policies on automobiles or divorces. A recent issue brief by The Commonwealth Fund, Administrative Compensation for Medical Injuries: Lessons from Three Foreign Systems. They write:

Several countries, including New Zealand, Sweden, and Denmark, have replaced litigation with administrative compensation systems for patients who experience an avoidable medical injury. Sometimes called “no-fault” systems, such schemes enable patients to file claims for compensation without using an attorney…. The systems have successfully limited liability costs while improving injured patients’ access to compensation.

It is time for us to move past the blame game to looking for solutions to problems. Let’s find better methods of addressing the needs for patients’ compensation, and for learning from mistakes to create a higher quality health care system.

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