I have remarked from time to time about the curtain of secrecy the medical profession has erected to hide from patients and the public their medical errors. Whether it is improperly sterilized endoscopes, settlements with injured patients, hospital investigations into botched operations or any of the many other events which the medical profession finds it embarrassing or inconvenient to reveal, the profession and the law have conspired to keep these things behind the curtain of secrecy. However, from time to time the curtain opens, if only briefly, to allow the public to see that indeed there is malpractice and that it hurts and kills patients on a daily basis. The curtain parted last week when the highly respected Massachusetts General Hospital reported on its investigation into medication errors during surgery at its institution. Here is a story from CBS News describing the investigation. The report of the actual study appeared on line in the peer reviewed journal, Anesthesia.
The hospital examined 277 randomly selected operations which took place over an 8 month period. The 277 operations involved almost 4,000 medication administrations. The investigators found at least one medication error in almost 50% of the surgeries they examined. The mistakes included improperly labeling the medication, dosing errors, mistakes in documenting the medication administration and failing to properly address changes in the patient’s condition brought about by the medication administration. Almost 80% of the errors were deemed to be preventable. 65% of the errors were “serious,” 33% were “significant” and 2% were life-threatening.
As surprising and shocking as these findings may be to a layperson, the study’s author, an assistant professor of anesthesiology at Harvard, says that things are probably worse at other hospitals as Mass General is a leader in patient safety and has gone out of its way to address this very issue. Her comments about how bad it may be at other institutions are hardly reassuring. The CBS story quotes the director of the Yale University Prevention Research Center as saying that the “numbers are disturbing but not surprising. Those of us who have worked in hospitals have seen innumerable instances when such errors did occur, or could have.” Feeling safer yet?
Hospitals, doctors and nurses do the best they can, often in difficult circumstances. Surgery is a challenging environment when things can and do go wrong despite the best efforts of everyone involved. The lesson to be learned here is that, even at the best hospitals, errors happen and happen frequently. There should be a system in place to compensate patients when they are injured by medical mistakes but the first step is to be candid with patients when you injure them through a medical mistake. Today, that almost never happens.
