We've all seen the articles in bold headlines, claiming medical errors are now the third largest cause of death. It's all the rage these days, since a new study came out stating that medical errors kill about 250,000 people a year. Yet, the Centers for Disease Control and Prevention doesn't require billing code error reporting in data it collects about deaths, so it's impossible to put an actual number on anything. What's going on here, what does it all mean, and, most important, what can we do about it?
Medical error is failure of a planned action, or use of an erroneous plan. It has been found that the highest error rates are most likely to occur in the ICU, operating rooms, and emergency departments.
Personally, my favorite part of this recent uproar is that none of this is news. The articles all tote the operative word “now,” but medical error leading to death at a high rate has been a topic of discussion for years. The Institute of Medicine released a report in 1999 regarding this issue, and, since then, there has been an effort to reduce error by putting in protocols.
So why is any of this even news if it's not new? Because people like to have something to blame for death, and medical (human) error is a great scapegoat. Bad outcome is the main driver of the litigation system; it's not a matter of someone making a mistake; it's just bad outcome, even if there is no one to blame. We live in a community of placing blame, and understandably so; it's easier to point a finger than to accept that sometimes people just die.
None of the new studies show that deaths from medical error have increased since the initial IOM report years ago. Better yet, Makary (head of one study) extrapolated his figure of 250,000 deaths from previously published papers, which had a total of 35 apparently preventable deaths. Yes, 35.
I think it comes down to the difficulty of actually defining whether a death was caused by medical error. While there are some clear-cut deaths due to medical error – like overdosing a patient – there are many more instances where cause of death is difficult to pinpoint – like a patient being seen 10 minutes later because there was a shift change happening. Did those 10 minutes cause the death, or would the patient have passed no matter when they were seen? This is not to say that medical errors do not exist. They do. It's just extremely difficult to determine if a death was caused by medical error, or if it simply was that patient's time to go.
The other thing we have to consider when seeing that medical error is now the third-leading cause of death is the fact that other causes of death have been drastically reduced over the past few years. David Wilcox, MD, FACEP, states, “Part of medical error being the third highest has to do with the fact that we have done such a good job at reducing other causes of death, such as heart disease. Cancer is going to become No. 1 soon, not because it is becoming more common, but because we continue to reduce heart disease [the current No. 1].”
Whether these reports are actually presenting anything new or groundbreaking, they are at least doing one thing right: they are re-opening the discussion on how to reduce medical error. Especially in the emergency department, we work in critical situations, with vulnerable patients. You can't be perfect all the time, but you can certainly try to reduce the number of errors that occur. And that's all errors, not just the ones that lead to death.
It's sometimes hard to believe that as medical students and residents we can make any impact on this issue – some of us are not even practitioners yet; what are we supposed to do to reduce medical error? First, acknowledge and accept the fact that we are human and will make mistakes. Then, realize there are steps we can take to minimize error. During your training, focus on physical exams and histories. Our best instruments are our hands, eyes, and ears, so get used to using them. Don't just think, “OK, it's chest pain, so I need to order XYZ” and then turn off your brain. Perform a complete physical exam. This will help narrow down what you need to focus on, where the actual problem may lie, and it will ultimately guide your decision-making. (It will also help eliminate extraneous tests/imaging, but that topic is another matter.) Form habits and checklists for seeing patients. Create a flow for seeing patients, and have a checklist of tests/imaging/follow-up necessary for each differential diagnosis you are considering after your full physical and history.
Electronic medical records were supposed to help alleviate high rates of error. Unfortunately, their effectiveness has not yet come to fruition, mostly due to inability to share records between systems. As the future of medicine, we need to get involved in the efforts working toward a cohesive EMR system where information can easily be shared from provider to provider. Until such a system exists, we need to maintain open communication with our colleagues. Practice this while in school/residency. Much like a game of telephone, each time a patient's story is handed off, it will inevitably be altered. Work to a point where you are able to communicate a patient encounter to a colleague with minimal error. Carry this game of professional telephone on with you as you enter rotations, graduate to residency, and eventually become physicians.
As the future of medicine, it's up to us to ensure maximization of leadership, attention, and resources to help minimize medical error. Humans are prone to error, but we are also beings with the ability to tackle challenges and find solutions to problems we face.
In an occupation that lives by the mantra of “do no harm,” daily errors are made, some ending in death; then again, to err is human. We can't expect the medical profession to be completely error-free, but we can lessen the frequency of errors. As you go through school, residency, and beyond, keep in mind that sometimes a patient is just going to die, no matter what we do. As Dr. Wilcox says, “We all have that terminal condition called ”˜life.' None of us are going to get out alive.” For some patients, it may just be their time; for those for whom it is not, let's keep to our oath and do no harm.