Fatal errors push hospitals to make big changes

Willie King went into a hospital and came out with the wrong leg amputated. Teenager Jesica Santillan died after she received a heart-lung transplant of the wrong blood type. Betsy Lehman, a medical reporter and mother of two, accidentally received fatal doses of chemotherapy four times what was intended. Ramon Vasquez died after he took the wrong heart medication when a pharmacist misinterpreted his doctor's handwritten prescription. Later, only a third of 158 doctors who were shown the prescription could identify the correct drug.

In the past decade, news of these and other medical errors has put human faces on what for many years was an invisible problem: deaths and serious injuries caused by medical mistreatment. As many as 98,000 deaths are caused by medical mistakes in hospitals each year. Now, a reform movement has begun to address these problems and is pushing radical changes in the way medicine is practiced in the United States.

Some are simple procedural reforms, from remembering to wash hands before touching patients to marking the correct site on the body for surgery. Others will require revolutionary and sometimes expensive changes in the medical culture.

Paradoxically, as more and more treatment options become available to patients in the 21st-century hospital, safety is becoming harder - not easier - to maintain. The number of drug choices, for example, has exploded in recent years, increasing the risk of mistakes. Hospitals have become hives of busy, sometimes exhausted, workers and complex systems in which a breakdown at myriad points can lead to tragedy.

How tragic began to come clear five years ago, when the respected and influential Institute of Medicine (IOM), part of the National Academy of Sciences, released a report called "To Err Is Human." It showed that about 1 of every 200 patients admitted to a hospital died because of a treatment mistake - as many as 98,000 fatalities a year. That was more, the report noted, than died in 1998 from highway accidents (43,458), breast cancer (42,297), or AIDS (16,516). While some critics later attacked the number as merely a loosely supported estimate, others contended that because of widespread undercounting, the number was almost certainly far too low.

"There's something about that report that struck pay dirt in the American psyche and the health-profession psyche," says Robert Wachter, a professor of medicine at the University of California at San Francisco and coauthor with Kaveh Shojania of the book "Internal Bleeding: The Truth Behind America's Terrifying Epidemic of Medical Mistakes," published earlier this year. "We discovered the epidemic of medical mistakes with the IOM report."

The IOM report also called for a review in five years "to assess progress in making the health system safer," a deadline that is now only months away. That grade is likely to be an "incomplete," reformers say.

"You can practically taste [the reforms] they're so close, yet we don't seem to be able to make them happen," says Lucian Leape, a professor at the Harvard School of Public Health who is considered by many to be the leading expert on medical errors.

Among the successes are changes in procedures, like requiring nurses or pharmacists to read medication orders back to physicians when doctors order by phone. "Before [the IOM report] there were few meaningful regulations on safety, and those that existed weren't enforced very effectively. I think that has changed," Dr. Wachter says. But this amounts to only a few things that are "relatively easy and don't gore that many sacred cows and don't cost that much money."

They are worth doing, of course. At his own hospital, Wachter says, a patient recently remarked that the nurses were asking her for her name "about 30 times a day," to make sure they were treating the right patient. "That would never have happened five years ago," he says.

Last week, the Joint Commission for Accrediting Healthcare Organizations (JCAHO) put in place new protocols for surgery. They included requirements to mark the site of a surgery, with the patient's cooperation if possible, using an indelible marker, and checklists before and after entering the operating room, meant to ensure that the patient receives the right surgery on the correct body part.

"These [errors] are completely preventable, we think," says Russell Massaro, JCAHO's executive vice president for accreditation operations. JCAHO currently receives a half-dozen or so voluntary reports per month on surgical errors, many with tragic results. "We want to make the number zero," he says.

But more broadly, what's been revealed is a flawed system that places "little or no value on investments in patient safety and demonstrated reductions in medical errors" because the payers, whether insurers or health-maintenance organizations, "pay the same reimbursement for unsafe as they do for safe care," said Dennis O'Leary, the president of JCAHO, in testimony before a congressional committee last year.

One hope for change lies in these payers insisting on reforms, because the same changes that improve safety also cut costs, says Nancy Ridley, director of the Betsy Lehman Center for Patient Safety and Medical Error Prevention in Boston. Right now, when more treatment is required to correct a mistake, payers "gladly pay twice for the same work," something that customers would never allow in other industries.

While numerous specific changes are needed, a mental shift is at their core. "We're really talking about a massive change in the culture of healthcare," Dr. Leape says. "It's a 19th-century culture in the 21st century. It's very hierarchical, very status-oriented, very compartmentalized."

Pilots as models

Healthcare now is looking at aviation as a model for teamwork and error prevention. One survey showed that 80 percent of surgeons said they thought teamwork in their operating room was great, Wachter says. But only 10 to 50 percent of the others in the room, such as nurses, agreed. "The leader is the last person you want to ask about how good teamwork is," he says. When asked if they should be immediately notified if something is wrong, pilots say, "Of course, are you crazy?" Wachter adds. But surgeons say, "No. I'm busy and can't be interrupted."

Wachter is starting a program for pilots to come to his hospital and train doctors in teamwork. "In some ways they're just as arrogant a species as surgeons are," Wachter says. "It's a colossal act of arrogance to fly a 747 across an ocean. But they know if they make a terrible mistake and nobody corrects them, not only do 300 people behind them die, so do they. And for better or worse, we [doctors] lack that incentive."

A number of promising "little experiments" are scattered among the nation's 5,000 hospitals, Leape says. Neonatal intensive care units at a group of hospitals around the country share information on problems and procedures, and anesthesiologists have drastically cut their errors by sharing information and agreeing on standards for equipment and practices.

Nearly half of states (21) now require hospitals to report to them on medical errors that lead to deaths or serious injuries, and Pennsylvania even requires that "near misses" be reported, says Jill Rosenthal, a patient-safety expert at the National Academy for State Health Policy in Portland, Maine. But she also sees "real anxiety and controversy about reporting [errors] to patients or reporting to the public," she adds, "because there's just a lot of fear on the part of the facilities that it's going to lead to lawsuits or it's going to shame the hospital's reputation."

That's why Wachter, Leape, and other reformers don't want to get hung up waiting for better error reporting. "The error rate in most hospitals is so substantial that you don't need to [know the number] to know what to do," Leape says.

The biggest step forward, reformers agree, will come when computers are widely used to keep track of all of a hospital's records, from patient files to inventories. A report late last year by the IOM called on the federal Department of Health and Human Services to take the lead in a public-private effort to push the use of technology. HHS Secretary Tommy Thompson has responded by naming a healthcare-technology czar and says his department will unveil at least part of its strategy in a report later this month.

"If you look at medical mistakes, about 80 percent of them are communication failures," Leape says, "and computers can eliminate a lot of them." But he remains skeptical of the federal effort, which he says includes only token funding. "What we're seeing now is ... giving it great lip service but no money," he says. The only places that have computerized medical records are Britain and the hospitals of the Department of Veterans Affairs in the US. "The thing they both have in common is that the government paid for it," he says.

Amazingly, for all their 21st-century technology, only about 3 percent of hospitals have computerized order-entry and patient records, Wachter says. The problem is that computerizing hospital information is not only expensive, it's far more complex than just buying computers. "You have to truly understand ... how things really happen in a hospital," he says. "If you just computerize the old way you've done things, you've computerized wackiness, because you've accreted these layers of nonsensical processes over the years."

Better prescriptions

Reformers are optimistic, however. In 10 years, doctors' handwritten prescriptions will seem archaic. Doctors will marvel that "we used to transmit information about toxic drugs using our handwriting. Can you believe that?" Wachter says.

While applauding efforts to empower patients to take charge of their own care, he also finds the need for it troubling. Many people come to hospitals accompanied by loved ones who plan to watch over them 24 hours a day to guard their safety.

If hospitalized today, "I guess I'd want that too," Wachter says. "But we have to step back and see how crazy that is. How is it that you as a patient, sick and anxious, can come into the modern American hospital and feel like you have to bring someone with you to make sure we don't give you the wrong medicine or cut off the wrong leg? It's fundamentally wrong."

At the end of the day, he says, "In our particular Oz there's too much happening behind the curtain for patients to protect themselves. Most of the time, it's really going to be up to the system and [medical professionals] to make it safer."





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