Malpractice — same problems over and over

What causes medical malpractice suits for health care providers and hospitals?  The simple answer is ERROR.  The most serious errors happen in hospitals but the most frequent errors happen in outpatient clinics.

James Reason (“Human error: models and management.” Bmj 320.7237 (2000): 768-770) is well known for his study of the causes of human error.   He breaks error into 3 main categories:

  1. Skill based error (not paying attention to the right things)
  2. Rule based error (not following the right rule or following an incorrect rule)
  3. Knowledge based error (not knowing or incorrectly concluding)

Health care providers make human errors all the time.   When the error actually causes injury the injured party will sometimes seek compensation through the legal system.

If humans “do the best they can” performing a task the error rate is about 10%.  For example, if a nurse is to administer a medication to a given patient there will be an error 1 out of 10 times.  Wrong patient, wrong medication, wrong dose, or wrong time just to name a few possibilities.  The goal in error reduction is an error rate in the 1 out of a million range.  Humans alone can not do that!  Prevention of errors absolutely requires systems — sometimes as simple as a checklist or sometimes as complex as a robot that packages medications with a barcode and later scanning of the code before drug administration to a patient.

Medical malpractice suits (excluding the presence of legal malpractice) arise out of a failure to have adequate systems to control error.  But, malpractice suits are only the tip of the error iceberg.  All interventions in health care must have active quality monitoring and error prevention systems.  Health care providers, to their patient’s detriment, yearn for simpler times — just the good old doctor-patient relationship in a small office with low overhead costs and no malpractice lawyers.  Without a focus on quality and standards the good old days were really the bad old days of medical care.

The cost of medical malpractice to the US healthcare system is estimated at $55 billion or 2.4% of the overall system cost.  However, the statistic misses the point.  How much is spent on preventing errors?  A wonderful trade-off would be to spend that much money to prevent errors in the first place rather than paying compensation for errors after they happen.  Lawyers say they see the same errors over and over.  One patient, one error, one trial then repeat with no intent to stop the cycle.  This is a major flaw in the US justice system.  Each settlement and each trial should result in some change to the system where the error happened.  The usual outcome is “it’s your fault”, “try harder” and “do the best you can” — which are clearly failed quality strategies.

Prevention of errors is a costly endeavor (although well worth the cost).  The following are examples of systems to reduce errors:

  • Electronic medical records
  • Electronic prescribing (computer checks for mistakes)
  • Checklists for surgeons
  • A strong quality management program both inpatient and outpatient
  • Standardized orders in the hospital
  • Standardized protocols for outpatient treatment
  • Mandatory involvement of health care providers in quality improvement
  • Development of a culture of safety for health care providers
  • Formalized hand-off when changing shifts or going off call
  • Barcoded medication administration
  • Robotic packaging of medications
  • Hourly nurse rounding to prevent falls
  • Include the patient in the effort to improve safety

The above list is seriously incomplete.  Health care is complex and changing.  The systems to prevent error need to be adapted to the circumstances and to our changing understanding of treatment.

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