Tuesday, October 06, 2015

An error about mistakes

There are few neurologists I admire more than Martin Samuels, chief of service at Brigham and Women's Hospital in Boston.  So it truly pains me to see him engaging in a convoluted approach to the issue of mistakes.  Read the whole thing and then come back and see what you think about the excerpts I've chosen:

The current medical culture is obsessed with perfect replication and avoidance of error. This stemmed from the 1999 alarmist report of the National Academy of Medicine, entitled “To Err is Human,” in which the absurd conclusion was propagated that more patients died from medical errors than from breast cancer, heart disease and stroke combined; now updated by The National Academy of Medicine’s (formerly the IOM) new white paper on the epidemic of diagnostic error.

No, the obsession, if there is an obsession, is not about perfect replication and avoidance of error.  The focus is on determining the causes of preventable harm and applying the scientific method to design experiments to obviate the causes.  The plan is, to the extent practicable, implement strategies to help avoid such harm.

[T]here is actually no convincing evidence that studying these mistakes and using various contrivances to focus on them, reduces their frequency whatsoever.

Yes, there is convincing evidence (from Peter Pronovost's work on central line protocols, for example) that the frequency of errors that lead to preventable harm can be dramatically, and sustainably, reduced.

For example, there is absolutely no reason to believe that a comprehensive medical record will reduce the frequency of cognitive errors, whereas it is evident that efforts to populate this type of record can remove the doctor’s focus from the patient and place it on the device.  

Well, here's one place we agree! EHRs might actually increase the chance of cognitive errors. But why would you pick that one example, Martin?

We all try to avoid errors but none of us will succeed. This is fortunate as errors are the only road to progress. Focusing on the evil of errors takes our attention away from the real enemy, which is illness. We should relax and enjoy the fact that we are lucky enough to be doctors. 

There are errors that lead to progress and there are errors that lead to death and other harm. The flaw in Martin's article is not so much what he says, as the extrapolation he makes from what he says.  A friend sent me a note summarizing the case nicely:

While I agree that we’ll probably never achieve zero errors in healthcare for a number of valid reasons, there is ample evidence that a systematic approach based on the scientific method can significantly reduce harm to patients.  Yet, there is no reference to the great work done by so many of his colleagues, e.g., Peter Pronovost, Lucian Leape, Donald Berwick, John Toussaint, Robert Wachter and Gary Kaplan, just to name a few.  Nor is there any empathy toward the patient and the impact of avoidable harm on his or her life


Carole said...

This is a topic I feel very strongly about, because I lost a family member due to errors, mistakes, negligence- yes all three words would describe what she and I experienced. I'm not giving details so I shouldn't be silenced to speak my mind.
I understand this term " to err is human " was created as an inspiration to help healthcare improvements, however as someone ( family ) who is a victim of this reality- I resent it. The nonchalant uncaring excuse or reason " hey, we're just humans- stuff happens" adds insult to injury and sets in stone a distrust even more so because of that attitude for all patients who have been harmed and families who lost loved ones.
It is not acceptable for patients to be harmed by the healthcare system that is suppose to offer healing and compassion a system that we should be able to trust in and depend on because there's a promise " first do no harm " .
A promise that is not made to us and should be is, " we promise to be honest and truthful, we promise to own errors, apologize, do right by you and all others by correcting them, keeping you informed and not repeating them to the best of our ability.
Unfortunately, but a great excuse and reason for the healthcare system we're just mere human beings who make mistakes and promises we can not keep. So pray for the best and prepare for the worst, what else can we do?

Melissa Clarkson said...

I read Dr. Samuel’s essay three times. Paul, your characterization as “convoluted” is an understatement.

Characterizing the 1999 “To Err is Human” report as “alarmist” is a slap in the face to those whose lives have been destroyed by medical errors.

I have tried to understand Dr. Samuel’s perspective, and two statements jumped out to me as quite revealing:

“The futile crusade for the eradication of error by ever more perfect guidelines and computer programs will only produce robots, which can only do exactly as they are told.”

“Doctors must make myriad mistakes, recognize them for what they are and change gradually as a result of the tiny percentage of them that make one better adapted to the environment, whatever that may be. This process is not controlled by our free will. We all try to avoid errors but none of us will succeed. This is fortunate as errors are the only road to progress.”

Perhaps these statements might make sense in another context, such as the restaurant industry. Imagine with me…

You are a hard-working member of the kitchen staff at a well-known restaurant. You are working your way up the ranks. Most days you follow the recipes, just as trained by the lead chef. But something deep inside of you knows you are capable of more. And so sometimes you do things a little differently — sometimes you make changes to the dishes because you are short of ingredients, and sometimes you just want to. Most of these altered dishes lead to customers who are very displeased with their meal. Some even leave in anger. But, after hundreds of failures and unhappy customers, finally your moment has arrived — a new dish is born!

I suppose if the consequences of errors are as minor as a ruined meal, errors are not a big deal. But if it is a patient’s life, I disagree.

nonlocal MD said...

This post, especially when viewed concomitantly with the previous one about protocols, is extremely revealing. If, as Paul says, the protocol in question previously was an unassailable one and therefore that doctor was wrong also, then what we have here is more evidence of nothing less than civil war within the medical profession. This has been brewing for some time, as we all know, but rather than dismissing it as a few old doctors who won't go along with the program, I think it is critical to recognize it for what it is - a major backlash - and take it seriously. For a department chair at a major academic center to take such a dismissive attitude toward both science and the patient is astonishing, and just points up how disturbing this issue is.
Rather than turning on all such skeptics with predictable Twitter-style internet bashing (which will only lead to more resentment and resistance), we should take steps to address their concerns. Whatever those steps may be.

Howard Luks said...

From Facebook:

If I didn't transform my role from son to physician I would have lost my father twice to serious (and easily avoidable) errors. Your characterization was accurate. #very #sad.

Norma Sandrock said...

From Facebook:

Neurology is so different from other specialties and its "errors" are different from the kinds of errors we can address through process improvement. He speaks from a very limited point of view but unfortunately generalizes beyond his expertise.

Laura Joy Gold said...

From Facebook:

Interesting and scary.

Emily DeVoto said...

From Facebook:

"We should all relax and enjoy the fact that we are lucky enough to be doctors." Ew. Ew. Ew.

Charlie Kenney said...

Dr. Samuels makes some useful points but he misses the significance of the IOM report ``To Err is Human,'' deriding it as ``alarmist.'' Since the report was issued in 1999, countless physicians, nurses, administrators and others have been spurred to action on safety by the report's findings. It stands as a important landmark in the ongoing effort in medicine to reduce error and keep patients safe. Much of the work on hospital acquired infections, falls, medication safety and much more can be traced back to the lessons and sense of urgency created by ``To Err.''

Barbara said...

I totally agree with your friend’s summarization of the case. And, I find it most distressing that Dr. Martin Samuels did not feel or voice “any empathy towards the patient and the impact of avoidable harm on his or her life” and that of the patient’s family.

David Joyce MD said...

He has one thing right, being a doctor is special. If those in other industries took the same liberties toward errors as physicians we would not have many of them left. GM makes a car that kills some of those who use it because the key falls out. Toyota makes some cars that kill people because of a sticking accelerator. Doctors kill 1000s of times more with systematic mistakes of systems that they control. I think I will relax too. Probably not!

A Facebook dialogue-Part 1 said...

A Facebook dialogue:

David States: I think you are misreading this. If we all followed uniform protocols rigidly, we would never learn anything from clinical experience. Research in the context of on-going care is possible, but it requires deviation between treatment groups and by definition that means one group is not going to receive optimal care. Of course, we don't know which group receives optimal care until after we do the study. The CRASH study on corticosteroids in head injury was controversial because many felt it would harm patients, but in the end demonstrated that the prevailing dogma was wrong (http://www.biomedcentral.com/content/pdf/cc3813.pdf). What motivated the CRASH study? Neurologists who realized that the patients who had "mistakenly" not received steroids as per protocol seemed to do better than those who had been treated per protocol.

A real issue is that the patient safety community has gotten ahead of itself in its enthusiasm. "Critical" warning popups are introduced willy nilly and well before anyone has gathered evidence that they don't do more harm than good. Just as it was obvious that corticosteroids would benefit head injury, it is assumed to be obvious that the many interventions of medical error scolds will improve care without considering the possibility that the distracted and delayed doctoring resulting from these interventions may be a net harm to patients. No question we can do better, but even Dr. Gawande's much touted success with surgical checklists is not easily replicated. Their use may be more a reflection of an institutional commitment to safety rather than the evidence of effectiveness of that particular intervention.
Paul Levy: It is a straw man to talk about following protocols rigidly. That's not the issue and seldom is--although do we really want creativity applied to the insertion of a central line? (Not usually.) That's not "distracted and delayed doctoring." The issue is Martin's lack of acknowledgement that thoughtfully design clinical process improvement saves lives and avoids harm to patients.
David States: Samuels argues for review to drive process improvement, and I would be very surprised if he did not support the use of evidence based central line protocols. What I think he is objecting to more is the rigidity of many protocol proponents. Would you prefer that a central line not be inserted if the injuries sustained in an MVA made it impossible to strictly follow each step of a protocol? But too often deviations such as the use of an accessible vein when the preferred entry site is obstructed are scored as errors.

EMR pop ups and warnings absolutely are a cause of distracted and delayed doctoring and few are subject to evaluation before they are inflicted on the physician community. We are now a decade into EMR deployment at many centers. There are plenty of studies documenting acute disruptions of care when EMRs are introduced. Where are the long term follow up studies showing enhanced physician productivity and improved patient safety? Ironic that patient safety advocates are so willing to ignore their recommendations when it comes to their own work.

A Facebook dialogue-Part 2 said...

Part 2

Paul Levy: You're mixing up EMRs and process improvement. Also, where you and he say "many" protocol proponents, I don't see that form of groundswell. Frankly, he just comes across as a pissed-off (perhaps because of the EMR point) and overly sure of himself arrogant guy. You say, "I would be very surprised etc" but he never suggests that such an approach is the way to go--especially as he also dismisses the idea that the extent of preventable harm is worth worrying about. Maybe he believes what you say he believes and just needs to learn to write better.
Paul Levy: BTW, your use of this argument-- "Would you prefer that a central line not be inserted if the injuries sustained in an MVA made it impossible to strictly follow each step of a protocol?" --is also an example of creating a straw man to offer an absurd conclusion. Wherever I've seen protocols put in place, the clinician always has the right and duty to override them if the circumstances warrant--based solely on that clinician's expert judgment.

Carole said...

Mr. Levy,
So there must be protocols for deviations, right?

Paul Levy said...

As noted by a commenter on my other post:

Standardized Clinical Assessment and Management plans (SCAMPS) which ironically were developed at the Brigham and Boston Children's provide an excellent clinician-designed approach to protocols that accommodate patient differences and acts as a living document to account for new evidence and technology. By physicians explaining any deviation the document continues to evolve while promoting standardization where appropriate. http://content.healthaffairs.org/content/32/5/911.full

Carole said...

Thank you, and with that being said...
It does give Doctors and Nurses the freedom to deviate from baseline protocols. Then that should be understood and excepted.
There are several families across the u.s who've lost loved ones to errors, mistakes and negligence who are communicating with one another, sharing stories comparing similarities. Because of their experiences there is a major distrust in hospital protocols being violated vs. medical protocols being deviated from. One gentleman said to me it's all about protecting everyone from liability and a lot less about patient protection and care. Which is exactly why they believe errors are hidden, and no one cares to take responsibility, and they never will.

Emuaid Reviews said...

Sometimes we cannot skip an error especially when you are doing a very critical things specifically for a patients. If you are a Doctor, you always have to make sure that you prescribe an exact medication to your patients. But in addition, sometimes, many mistakes do not result in death they can and do create additional medical problems for patients. It would go a long way for patients peace of mind and recovery if all doctors would admit to mistakes, take corrective action, and apologize. I believe there would be a lot FEWER lawsuits.

Unknown said...

I would just like to mention that the reactionary responses to some, or most medical errors I see is to add some crazy step that all too often really only applies to the original error, situation and cast. The time suck that new locked rooms and storage places and statements to read and cosigns to be gotten in order to get my work done can lead to many doing 'work arounds' cultures of collusion exist. I have run up against them. Groups/units that essentially lie about what they do. Actual patient care that is important to improved recovery goes by the way side. The 'bottom line' only thinking about delivery of care being mandated by non bedside employees puts pressure to perform. People find shortcuts. I have had nurses say sometimes doing what is right for the patient trumps true 'honesty'. In regards to charting etc. I have had a manager tell me that giving my patients medications on time. period, is how it is. Agree that certain medications are a given that time sensitive issues exist. Reality is that patients dont all take there medications at home as we insist they are given in a clinical setting. Getting them out of bed. Giving a real bath not just a minimal wipe with chlorhexidine cloths is not a priority. I could list other instances where the new culture of healthcare is all about certain markers than patient outcomes. Charges getting in, charting looking as if perfect care is given -yet takes away the time you would 'actually be doing perfect care' dealing with systems that are time sucks. Critical thinking is being squashed. Healthcare delivery, done safely, is so dynamic. Best care varies from region, to cultures in place, to systems reliability, to family assistance or hinderance, patient compliance, effort, ethnicity. Effective safe care is more like snowflakes. All fragile, spectacular and different. One size doesnt fit all.

Paul Levy said...

Well said, and an important point.