Safe Medical Care – We Can Wish It or We Can Design It

Posted on | May 12, 2008 | Comments Off on Safe Medical Care – We Can Wish It or We Can Design It

Only a new medical system that incorporates safety systems designs will assure high quality medical care

Virtually everyone faced with the prospect of undergoing anesthesia for surgery has a fear of the ‘what if’ adverse outcome. In the early 1980s, anesthetic deaths for all patients were estimated to be about 1 in 10,000 procedures! If one applies this incidence to the number of anesthetics given in the U.S. today (about 40 million), 4,000 patients would die yearly because of an anesthetic mishap (breathing tube misplacement, drug reactions, wrong drug given)!

Fortunately, the vast majority of patients undergoing elective surgeries today have about a 1:250,000 risk of dying or only 4-5 patients per 1,000,000 anesthetics.

One might take consolation in knowing that the medical practice of anesthesiology has become the ‘poster child’ for safe patient care by the prestigious Institute of Medicine¹. Ironically, driving to the hospital on the day of surgery is six times more risky than having the anesthetic. Nonetheless, medical statistics are for dead people – families, whose loved one is now about to become the newest statistic, will not be consoled by knowing how safe anesthesia could be.

There’s a cost for maintaining a very safe patient environment. Often, making anything 100% safe can cost ten-fold more than making something 95% safe. In the current health care environment, further increases in the high cost of medical care is an unacceptable strategy. Cost-driven health care is the mantra for Congress, HMO’s, small businesses, AARP and the patient. This cost-driven paradigm expects patient safety to be paramount, but with payment caps. Doctors are concerned about a reduction in the access to care and a concomitant erosion of high quality care.

Reducing payments does not necessarily result in poor quality or lack of access – just ask an airline pilot. Their salaries were reduced by as much as 20%, yet planes didn’t fall out of the sky and widespread work stoppages did not occur. Thus, payment caps or Medicare cuts are likely measures to try and rein in escalating health care costs.

Some argue that comparisons with airline pilots are flawed because adverse airline events directly affect the well-being of the pilot. In medicine, however, no physician awakens with the idea of causing harm to a patient. Adverse medical events, while not jeopardizing the life of the doctor, have a devastating and long-term impact on the physician’s quality of life. Malpractice suits, loss of self-esteem, lack of self-confidence, a ruined reputation, clinical depression, early retirement and even suicide can result from a physician committing a life-ending error when caring for a patient.

So, distilled to its essence, airline pilots keep us safe for fear of killing passengers and themselves, while doctors keep us safe for fear of causing harm and being sued. In both cases, there is a societal responsibility and a personal interest in maintaining safety.

The two industries, air travel and medicine, differ in safety by as much as a million-fold. Medicine is 96.3% safe, or stated another way, has an error ratio of 1:27 interactions. Air travel is 99.99997% safe with an error ratio of 1:30,000,000 flights. Parenthetically, anesthesia care is 99.9996% safe with a 1:250,000 error ratio; 12 times more dangerous than flying but about 10,000 times safer than medicine in general. The reason for greater safety in the airline and anesthesiology sectors is not due to smarter or more dedicated professionals but to the early implementation and continued improvement in safety systems that actively prevent human errors from occurring.

Relying on professionals to do the right thing out of a sense of duty or through fear (malpractice suits) totally ignores the fact that to err is human. People will make serious mistakes because of misinterpretations, knowledge deficits or persistent habits of thought, even when they try to avoid them. Only systems that:

1. Avoid Reliance on Memory

2. Simplify Tasks

3. Standardize Procedures and Equipment

4. Use Constraints and Forcing Functions

5. Use Protocols and Checklists Wisely

will move medicine out of its cottage industry practices into the modern world of systems design.

Who will do this, and why, seems to have an elusive answer. Instead of pointing fingers, everyone knows America’s health care system needs a new paradigm and not a remodeling. Whoever, wins the presidential election in November will be faced with the opportunity to engage ALL stakeholders into transforming health care. It will take at least a decade and we will make wrong decisions along the way. We can, however, take consolation in a quote by Sir Winston Churchill:

"Americans can always be counted on to do the right thing…after they have exhausted all other possibilities."

-MJL

1. Institute of Medicine. To Err Is Human: Building A Safer Health System. November 1999. http://www.iom.edu/Object.File/Master/4/117/ToErr-8pager.pdf