Tuesday, April 23, 2013

Physician Errors

A new study at the Johns Hopkins Medical Center revealed that diagnostic errors, which lead to injury as a result of delay or failure of treatment, are a greater contributor to physician error than treatment error. Their 25-year study of 350,706 paid malpractice claims, amounting to 38.8 billion dollars between 1986 and 2010, showed that diagnostic errors (missed diagnosis, wrong or delayed diagnosis), which accounted for 28.6 percent of total errors,  were more dangerous than errors in other categories.

According to lead study author Dr. David Newman-Toker, an associate professor of neurology at the Johns Hopkins University School of Medicine, “There’s more uncertainty about diagnostic errors than there are about treatment errors. It’s reasonable to say no nurse should ever administer a tenfold dose of chemotherapy or a medication to a patient allergic to that medication.  Those events are easier to keep track of and easier to measure.”

Diagnostic errors often take place when a patient is initially seen. Often, there is no individualized or hospital standardized system or recording diagnosis. If the same patient presents later with an unsolved problem, the error may be noted as a treatment error, instead of healthcare professionals noting that the right diagnosis was not made in the first place.

The study’s authors only studied errors that were found from malpractice suits, but estimated that the annual number of patients how suffer from preventable injury or death in the U.S. are between 80,000 and 160,000.

Dr. Newman-Toker suggested these solutions: Measurement and reporting of diagnostic error should be mandatory. A policy at the federal level to have hospitals report these statistics must be applied. Currently, many hospitals do not report diagnostic errors because of business and legal policies. Most importantly, physicians must more thoroughly record patient appointments. 

Recording should take place both in printed and electronic versions: Paper records may be lost or misplaced and physician writing is often notoriously illegible. Transfer to electronic records would allow the person transferring the records to make sure they are legible, would provide for an easily searchable and comparable records, and would provide a back up system to print records.

The Johns Hopkins study is the latest published study on medical error. Several studies  have shown that medical errors are a leading cause of death in the U.S. One study at Johns Hopkins University, published in 2000 in the Journal of the American Medical Association, showed that medical errors are the third leading cause of death: 2,000 deaths/year from unnecessary surgery; 7000 deaths/year from hospital medication errors; 20,000 deaths/year from other hospital errors; 80,000 deaths/year from infections in hospitals; 106,000 deaths/year from non-error, adverse effects of medications totaling 225,000 deaths per year.

Another study put medical errors at number six of causes of deaths per year in the U.S.: The Institute of Medicine’s (IOM) seminal study of preventable medical errors estimated as many as 98,000 people die every year. In November 2012, CNN medical producer John Bonifield and CNN Senior Medical Correspondent Elizabeth Cohen listed “10 shocking medical mistakes” that include lost patients with dementia, operating on the wrong body part, fake doctors, and leaving surgical equipment inside patients after an operation was complete.

Many may not believe that some of the errors would happen in the U.S., with its network of hospitals and experts, yet Stahel and colleagues from the Department of Orthopedic Surgery, at the University of Colorado School of Medicine reported that a total of 25 wrong-patient and 107 wrong-site procedures were identified during a study period of 5.5 years. Significant harm was noted in 43 events, as was one death. Causes for wrong-patient procedures were errors in diagnosis (56.0%) and errors in communication (100%), while wrong-site procedures were linked to errors in judgment (85.0%) and the lack of performing a "time-out" (72.0%). According to a 2004 Kaiser Family Foundation survey, one in three Americans say that they or a family member has experienced a medical error, and one in five say that a medical error has caused serious health problems or  even death.

As Fox News recently reported, the Accreditation Council for Graduate Medical Education (ACGME) introduced restrictions on intern work hours in 2003 and again in 2011. But even this seemingly simple change did not seem to have beneficial results: Although in a follow-up study weekly hours dropped from 67 to 64, the general sleeping hours, well-being and performance of interns did not improve.  

Dr. Sanjay Desai and colleagues from Johns Hopkins University in Baltimore assigned residents the 2003 and 2011 work shift hours. The more abbreviated 2011 work schedule actually led to a reduced quality of patient care, and did not reduce risk of depression among interns. Many interns reported that they had to accomplish the same amount of work in less hours, which led opt more errors.  Reduced hours led to an increased turnover of care, whereby one physician did not feel (or act) like they were primarily responsible for each patient.  Communication problems in reporting about the patient from one physician to another were increased during turnover. Also, fatigued second-year students often had to fill in the work, which was not much of a solution. Dr. Zachary F. Meisel from the Emergency Room Department at the Perelman School of Medicine at university of Pennsylvania suggested physician naps as one solution to decrease medial errors. He also pointed out that less hours means less training, so a balance has to be struck between too many and too few hours.

Physicians, although they may be trained by the same medical school curriculum, have their own cultural personal and patient history biases. Dr. Brian Goldman, speaking at TED, said that sometimes the most physicians can to is to try their best, be aware of their own biases that affect diagnosis and treatment, and remember any patients that were injured or died due ot medical errors.
According to a 2005 study by the Commonwealth Fund in spite of advances, such as the development of performance standards, an increase in error reporting, integration of information technology, and improved safety systems, the IOM and these recent articles show that more work needs to be done.
According to the 1999 IOM report, more than by individuals, errors are caused by “faulty systems, processes, and conditions that lead people to make mistakes or fail to prevent them”. Therefore, workplace organization management and communication systems to computer record-keeping systems must be reassessed and, where necessary, reorganized.  This may involve new practices and technology. The health care sector, according to Harvard University business professor Regina E. Herzlinger, is slow at adapting to innovation. This exits for several reasons, one of which is the different players with varying agendas. Another reason is the huge networks of fragmented care centers and systems of three or less physicians, 5,000 community hospitals and 17,000 nursing care centers.  If a patient is exposed to one of more of these centers, record-keeping and communication of records are of vital importance to prevent mistakes. Last but not least, many physicians and health care centers are committed and comfortable with the status quo.  Studies on what doesn’t work and on new systems that do work may persuade health center administrators and funders to adapt new systems that may decrease physician blunders.

According to  Dr. Herzlinger, hospitals, senior citizen centers, rehabilitation centers, pharmacies and other healthcare systems are not sufficiently linked in information sharing. It is often difficult for physicians seeing a patient for the first time to know the whole, exact patient history, medications taken, etc. that will affect diagnosis and treatment. The push for shared Electronic Health Records (EHR), for instance, is a push for health information sharing that will allow for doctors to know more details about a patient’s history. Add to this that many patients do not know or remember, especially if sick or incapacitated or if they have a language barrier, their own history, including drugs taken, very well. Another problem is that doctors are overworked.
To sum up, solutions may include:
  • Government policy to regulate record-keeping;
  • Physician checklists of what to ask patients and how to keep records;
  • Better, standardized, record-keeping;
  • Hospital recording and reporting of physician mistakes and studies into why such mistakes took place;
  • A balance between the right amount of training and rest of residents, interns and physicians;
  • Information sharing on patient histories and errors between hospital and other care centers for a. better case management and b. insights into why errors take place;
  • Patients must be informed of the potential of hospital error and must play a bigger part of their care;
  • The repealing of old laws that hinder healthcare innovations; and
  • New laws to make healthcare innovation more efficient and lucrative.
This is a complicated issue involving many players. But, with human life on the line and the increasing cost of healthcare, it is an issue that cannot be ignored or put on the sidelines.

My book Pocket Guide to Fitness is available on http://www.Authorhouse.com and http://www.Amazon.com. If you look up my name on those Web sites, you will find my other books The Boy in a Wheelchair and Life, Work and Play: Poems and Short Stories. These two books are on my Web site http://www.LouizaPatsis.com.Visit and like, if you so see fit, my book page at www.facebook.com/PocketGuidetoFitness


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