Medical mistakes are the 3rd leading cause of deaths in the US.
Only heart disease and cancer kill more people every year than medical mistakes ranging from "surgical complications that go unrecognized to mix-ups with the doses or types of medications patients receive."
And a new study from the ECRI Institute looks at a subset of these mistakes -- patient identification mix-ups -- finding that the magnitude of the problem is huge, and that the EMRs are not helping.
It's not that we shouldn't ever make a mistake, as healthcare providers.
In fact, I am proud that in the medical field, we have an ethos of looking at and learning from our own mistakes. Medicine is not an exact science, and we are still learning and evolving our practice. For instance, anesthesia was only invented about 150 years ago, so it's not shocking that we're still experiencing avoidable surgical complications. Some even say that we are "practicing medicine."
That said, the ECRI Institute looked at 7,613 wrong-patient errors at 181 health care organizations -- and many of these mistakes are surely avoidable.
The study cites examples like:
- A patient in cardiac arrest who wasn't resuscitated because the care team thought he was a different patient who had a do-not-resuscitate order.
- A patient who was not supposed to eat or drink but was provided with a meal and choked.
- An infant who received breast milk meant for another infant, leading to the child being infected with hepatitis.
Medicine is limited and I certainly don't expect that we won't make any mistakes. But when mistakes are made because we're not making the most of every member of the medical team, or because we're not communicating well -- that is unacceptable. In looking at the study, my response was embarrassment and anger. We have to be doing more, as a medical profession, to advance the healthcare collaboration and care coordination that would prevent these kinds of mistakes.
We see 3 key reasons for these heartbreaking mistakes:
- We're sidelining key people on the medical team.
Whether it's the orderly delivering a meal or a piece of equipment, medical support staff, the nurse giving a medication, or the specialist stopping by on the weekend -- we all have different types of information available to us and we all need to be informed and informing each other. I see a certain kind of arrogance reflected in these numbers. And it is the arrogance of not understanding that every person on the medical team -- regardless of where they are on the continuum of care -- must be part of the team.
- We're too rushed.
Perhaps it is no one's fault, or perhaps it is the fault of all of us. But we are in such a hurry, and so overloaded by administrative duties, that we are not taking time to do healthcare collaboration and care coordination. We are rushing through the simple things, and it is creating complex problems that are devastating in their long-term consequences.
- Care coordination simply isn't happening.
Care coordination isn't that complicated, but it has been shown to have dramatically positive effects when it comes to this kind of mistake. If the nurse and the specialist were both filled in on what happened in the last 12 hours, and had a simple way to ask and answer questions... if the nurse on the first shift and the nurse on the second shift could check in with each other asynchronously... these mistakes could be avoided... if they simply coordinated. There are simple and cheap solutions to making care coordination happen, so our excuses are fewer than ever.
So why is this situation -- in which basics like care coordination are overlooked and our mistakes are the 3rd leading cause of death for our patients -- allowed to persist? Well, as Dr. Makary shared in discussion about that Johns Hopkins study, "You have this over-appreciation and overestimate of things like cardiovascular disease, and a vast under-recognition of the place of medical care as the cause of death. That informs all our national health priorities and our research grants." That's exactly why, in the telemedicine field, it's trendy for money to go towards flashy health monitoring, and not the more foundational work of supporting dynamic healthcare collaboration. Our short-term thinking is literally killing our patients. It's time for us to think as a team, and do the important, transformative, and ultimately deeply satisfying work of care coordination -- that will save both healthcare and the patient in front of us.
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