Posted by Bill Sandweg on 29 July 2019.
Anyone who has ever been a hospital patient or who has had a loved one in the hospital has seen errors in care. They occur on almost a daily basis and they come in all shapes and sizes. Modern medical care is complex and involves many participants. Human nature being what it is, errors are certain to occur. Our goal should be to keep errors to the smallest number possible.
In a landmark study, To Err is Human: Building a Safer Health System, researchers at the Institute of Medicine estimated that between 44,000 and 98,000 patients die in hospitals in the United States each year as the result of preventable medical errors. That is a shocking number. While firm figures are naturally hard to come by, other studies have supported these general numbers. Some have even concluded that these numbers greatly underestimate the magnitude of the problem. Why are firm figures hard to come by? The answer is that very few health care providers are willing to admit they made a mistake which caused patient injury, much less one which caused a patient death.
To their credit, most hospitals today are trying to improve patient care by reducing the number of errors. They have created policies to avoid some of the most common errors. For example, most hospitals insist on a “time out” just prior to the commencement of surgery to double check that they have the right patient, the right procedure and the right body part. Another example is a system of checks to assure that providers wash their hands before every patient encounter. Most hospitals also have Morbidity and Mortality conferences at which cases are discussed to try and learn from what happened. While well-intentioned, these conferences don’t always work as well as they could.
The problem, of course, is that meaningful change and improvement cannot happen if everyone pretends that things are fine the way they are. Things are not fine the way they are but health care providers have a great many reasons for keeping their errors hidden.
In the first place, no one enjoys admitting they made a serious mistake. Admitting a mistake for a doctor can mean a loss of hospital privileges and a loss of privileges will almost certainly mean embarrassment and a loss of income. Admitting a mistake can also lead to Medical Board discipline, which can range from a simple letter of concern to loss of one’s medical license. Then, of course, admitting a mistake can lead to an expensive malpractice suit, even though such admissions are generally not admissible in the Arizona courts.
Progress is being made. It is slow but steady. On the other hand, medicine continues to become more complex and, while one avenue for error is being closed off, another one may be opening. We all just have to keep trying.