Why Do We Continue to Harm Patients?

WAKING UP TO A NIGHTMARE

Imagine waking up from surgery in a hospital bed - you can't move, you literally cannot speak, lift a finger or communicate that you are awake in any way. Over the next few days, as you drift in and out of consciousness, you realize from the conversations going on around you that you have been in the ICU for three weeks. Over the next weeks of recovery, you come to realize that during surgery - a standard hysterectomy for a diagnosis of uterine cancer - your bowel was nicked. Your post-operative pain was ignored for almost 36 hours, and you ended up septic and in the ICU. This story is from Anatomy of Medical Errors: The Patient in Room 2 by Donna Helen Crisp1 - she was a professor of nursing at the UNC school of nursing and this happened to her.

In another book about medical mistakes, Wall of Silence2, Rosemary Gibson and Janardan Prasad Singh, share horrifying stories of medical error, including a widower whose wife died of cancer that was spotted three years before her death but never treated, a woman who died from sepsis after hemorrhoid surgery, a man who was supposed to have his left lung operated on, but had the right one operated on instead. On the ProPublica Patient Safety Facebook page3 you can read daily accounts of the suffering of individuals from medical error. These are stories from people who have been harmed in our care - in the care of a system that was supposed to at least try to heal them.

PATIENT SAFETY

I am obsessed with patient safety and the prevention of harm from medical error. Wherever I go, I talk to people about my obsession, and people open up to me. At the National Patient Safety Conference in 2017, I bonded with a sales-rep over the death of his father, who had gone into the hospital a healthy 82-year-old needing a routine procedure. He died there 6 months later of pneumonia. At a local safety conference, I listened to a young nurse tell a roomful of her peers about an insulin error she was involved in. She bravely recounted her story so that we could learn from it.

A report in 2000 by the Institute of Medicine4 estimated that in healthcare, about 40,000 people die each year from medical error (this number is a gross underestimate - current estimates put deaths from a medical error at more like 400,000 people5). The IOM used an analogy that has haunted me since I read it. It is as if a jumbo jet, fully loaded with passengers, crashes each WEEK and there are NO SURVIVORS. If that happened, don't you think someone would get upset? And yet in healthcare, because these are silent, individual deaths, often covered up by shame, secrecy, and even illegal activities - nothing is done. There is no huge media circus each time one person dies as a result of a medical error, but the cumulative effect is catastrophic.

IMPACT

And what about the impact -- the harm done to patients and families, the needless millions of dollars spent by individuals, healthcare organizations and taxpayers, the emotional suffering of everyone involved - patient, family member, nurse, doctor...the entire healthcare team becomes the victim when an error occurs? The culture of blame and shame so rampant in health care adds to the impact of error by making it extremely difficult for those involved in errors to find support. Victims of medical error often suffer alone, in silence, isolated by an event over which they had no control.

LET'S TALK

Let's open a dialogue. I want your stories, but more importantly, I want your solutions. As nurses, we are in a prime position to impact patient safety because WE know the patient best- that's our job. We are taught in nursing school to "be careful" and to follow the five (or six, or nine, or 12) rights to prevent error, but despite this - nurses continue to make mistakes. In fact, it is unlikely that a nurse will complete their career without making an error6. Does that mean nurses who make errors are bad nurses? Does this mean they just weren't careful enough? Perhaps something else is going on? The modern patient safety movement suggests that instead of focusing on individual responsibility, we focus on SYSTEMS causes for errors - things we can change about our environment, working situation and organization to reduce harm from error.

What works for you? Please share some success stories with me as well as mistakes. I am going to be writing a lot about this topic in the months to come. I will be sharing interviews with nurses involved in error, guidelines for how to "mistake proof" your practice, and information you can USE. Keep your eyes open for safety checklists you can share with friends, family, and patients to prevent harm.

ONE THING

What ONE THING would you do today (the sky is the limit here folks) to reduce harm to patients? To get some ideas and solutions go to my favorite source - the National Patient Safety Foundation/Institute for Healthcare Improvement (NPSF/IHI). If you can't find any ideas there, try the Agency for Healthcare Research and Quality (AHRQ).

REFERENCES

1. Anatomy of Medical Errors

2. Wall of Silence

3. ProPublica Patient Safety Site - Facebook

4. Kohn, L., Corrigan, J., & Donaldson, M. (2000). (Editors). To err is human: Building a safer health system. Washington DC: National Academy Press.

5. Classen, D., Resar, R., Griffin, F. (2011). Global "trigger tool" shows that adverse events in hospitals may be ten times greater than previously measured. Health Affairs, 30, 581-9. doi: 10.1377/hlthaff.2011.0190.

6. Anderson, D. J., & Webster, C. S. (2001). A systems approach to the reduction of medication error on the hospital ward. Journal of Advanced Nursing, 35(1), 34-41.

7. NPSF/IHI

8. AHRQ