Altman, Lawrence K. "Medical Errors Bring Calls For Change," New York Times, 18 July

 

Altman, Lawrence K. "Medical Errors Bring Calls For Change," New York Times, 18 July
1995, p. C1, C8.

Here is the physician-reporter of the Times summarizing a thread of horror stories which have
recently made national news: the wrong leg amputated in a Florida hospital, killing overdoses of
anticancer drugs at a world-famous research center, a neurosurgeon operating on the wrong side
of the patient's brain, or a physician pumping a feeding solution through a dialysis tube. The
common thread to all these: there's a need to change the system that allows these kinds of things
to happen. "Medical errors that escaped attention in years past are now being recognized because
of public pressure that has led to increased accountability and improved detection." (p. C8)

"The medical profession has long preferred to handle errors in a secretive manner, but as a
number of doctors, hospitals and health officials have begun to emphasize the value of learning
from errors a few cracks in the secrecy have appeared in recent years. Among these efforts is a
study done in New York State in 1991 that analyzed the records of more than a million patients.
The study found a large number of preventable errors, but it has had ‘very little impact,' said Dr.
Mark R. Chassin, who was the state's Commissioner of Health until January."

There is a new perception of accountability: "The demand for accountability, (said Dr. Dennis S.
O'Leary, President of the Joint Commission on Accreditation of Healthcare Organizations) ‘has
to do with the fact that we are spending a trillion dollars a year on health care and people want to
know what they are getting for it.'" (p. C8)

"Much responsibility for certifying that health care institutions have adequate quality control
rests with the Joint Commission on Accreditation of Healthcare Organizations, known as
J.C.A.H.O., a private, non-profit, quasi-official group. The commission represents five
professional organizations: The American Medical Association, the American Hospital
Association, the American College of Physicians, The American College of Surgeons, and the
American Dental Association.

"Hospitals need such certification to become eligible for reimbursement from Medicare and
Medicaid which account for the overwhelming bulk of any hospital;s income.

"Commission inspectors survey 5,300 hospitals and 6,000 nursing homes and other health care
organizations. But the accreditation surveys take place only every three years and are generally
announced long in advance...

After news reports of some recent errors, the commission made unannounced inspections of
several of the hospitals that were involved, and it recommended lifting the accreditation of the
Tampa hospital where surgeons cut off the wrong leg. It also placed the Dana-Farber Hospital on
probation.

"The actions, prompted by publicity about specific errors, led many to ask how the J.C.A.H.O.
could find such serious fault with two hospitals that had received high marks in the last
inspections.

"‘The answer is clearly that they miss these things,' said Dr. Jerome P. Kassirer, the editor of The
New England Journal of Medicine. ‘The fact is that the J.C.A.H.O. does not always ask the right
questions, doesn't always look at the right information and relies on enormous mounds of
paperwork that have nothing to do with anything."

Methods of hospital inspections are being improved principally by relying less on documentary
proof and more on direct measurement of patient outcome.

Dr. Sidney M. Wolfe, of the Public Citizens Health Research Group in Washington, is very
critical of the accreditation process in that the commission is subject to inherent conflicts of
interest. "‘It is incredibly elaborate and expensive, and it leaves the consumer relying on these
private organizations that are basically trade organizations,' Dr. Wolfe said."

Very few hospitals ever lose accreditation, less than 1 percent, so that threat may be toothless.

"Although an error-free record seems beyond the reach of even the best hospital, experts like Dr.
Lucian L. Leape of the Harvard School of Public Health believe the number can be reduced
substantially with the institution of quality control systems. But before they can be put into place,
doctors and health care workers must be free to acknowledge mistakes. Without a no-fault
system, those who volunteer information about errors are vulnerable to malpractice suits.

"Conferences to discuss errors are rare in medicine. And medical centers that do examine
problems, such as hospital-acquired infections, often pay dearly in terms of adverse public
relations. The hospital that is slow to identify its problems often comes to be regarded as a good
hospital because its statistics look good." (p. C8)

There is no doubt that some incompetent physicians are the causes of errors and identifying them
and relying on malpractice suits has been the common sanction. But it is not only individual
incompetent: the system needs changing.

"One approach to a systematic solution involves computerization of record keeping. In some
hospitals, doctors write orders directly in a computer, which can then issue warnings when a
prescription might trigger adverse reactions in a vulnerable patient. At Brigham and Women's
Hospital in Boston, computers handle all the drugs in the hospital;s formulary and monitors their
risk to patients. It also provides a tool for reducing the errors frequently made during the
‘handoff' period, when the resident doctor goes home at night and is covered by another. The
covering resident is six times more likely to make an errors, the hospital has found, largely
because he has less information than the patient's own doctor.

"Computer systems can also prompt speedier responses when blood tests indicate a serious
condition, like a dangerously abnormal chemical level.

"Yet attempts to install such computer systems have not always been successful. At the
University of Virginia Health Sciences Center in 1988, for example, residents complained about
the four hours a day that some were spending at the computer terminal. Today, after extensive
discussion, the computer system is being used effectively.

"Driven by soaring premiums for malpractice insurance, leaders in the field of anesthesiology,
which has been particularly plagued by mistakes, have begun working with the insurance
industry to analyze claims and correct systematic errors. Borrowing on techniques used to train
airplane pilots, many medical centers have reduced anesthesia errors by using mannequins as
simulated patients in training students.

"Sometimes the problem is simply bad doctors, and efforts to identify them also have led to a
systematic approach.

"In 1986, Congress passed legislation creating the National Practitioner Data Bank to encourage
professional peer review and to restrict the ability of incompetent practitioners to move from
state to state would having their previous problems discovered.

"The data bank's principal purpose is to alert hospitals to doctors whose records are stained. The
list includes doctors who have been the subjects of malpractice awards or professional review
actions that have led to their clinical privileges being withdrawn for longer than 30 days. Since
Sept. 1, 1990, the data bank has received reports on more than 108,000 disciplinary actions and
malpractice payments involved more than 80,000 practitioners. About 82 percent of the reports
concerned malpractice payments. There were 14,500 actions taken against a health profession's
license; of these 79 percent involved medical doctors, and the remainder dentists.

"But the system is still in the early stages and has many critics. Its information is secret. And the
Inspector General of the Health and Human Services Department recently found that 75 percent
of hospitals in the United States had not reported a single doctor since the bank opened.

"Given that some mistakes are inevitable, pressure is mounting for the medical profession to
make use of the best quality control techniques available. Change seems inevitable. As David
Blumenthal, a health policy researcher at the Massachusetts General Hospital, wrote in the
Journal of the American Medical Association, ‘The only question now is whether new systems
for preventing medical error will be designed with the full cooperation and participation of the
profession or under less desirable circumstances.'"