The Antidote

Counterspin for Health Care and Health News

Monday, October 16, 2006

Tunnel vision and patient safety

An unsigned article from yesterday's AP wire, about a woman who was temporarily paralyzed from too rapid administration of a painkiller during childbirth, made me sad. Sad for the unfortunate patient, yes, but sadder still for the country's collective (mis)understanding of how such incidents really happen and, thus, what it takes to prevent them.

The article's lede describes a prior incident of medication error at the same hospital, in which three infants died, and then describes the current incident: Apparently the pump that delivers an epidural medication was misprogrammed, and the patient received 10 times the amount she should have over one hour (she recovered, and her baby was fine).

The article states that the hospital referred to the incident as a "doctor's mistake" - and the hospital's statement, not the putative mistake, to my mind, should have been the story. Clearly they were trying to shift the blame, but what does assigning blame do for you (the hospital that is) when what you really should be doing is getting busy figuring how this and the previous, more serious, incident happened in the first place? That means examining assiduously all of the hospital processes that take place in order for medication to get inside a patient: how medication orders are filled, the installation of the pump, instructions for operating it, how health care workers are trained to use the pump, procedures for double-checking dosages and drug names, etc., etc. It also means that you have to have data on adverse events and close calls, collected in a way that promotes understanding and facilitates prevention, and - this is the scary part for hospitals - in a non-punitive fashion. Of course, there are truly negligent practitioners out there, but the current system targets those who happen to be at the sharp end of the needle, as it were, when an error occurs.

This news story relates an anecdote or two, but medical errors are a real public health problem - such incidents lead to about 98,000 deaths per year. That's another opportunity missed by the AP writer - the opportunity to put this hospital's experience in context.

There's still time for reporters to go back to the hospital spokespeople and ask them what they're doing in terms of larger-scale changes. Are they working with organizations such as the Institute for Healthcare Improvement to reduce deaths from pneumonia and hospital-acquired infections? Are they training their executives to appreciate the business case for quality and systems' approaches to patient safety? Are they raising funds for electronic health records systems? Those are important stories, too, stories I hope consumers will come to ask for. They may not seem as gripping on the surface as stories about young moms paralyzed at the hand of negligent doctors, but in the end, they're about saving lives - many of them.

Some resources on patient safety (in addition to IHI, cited above):

AHRQ Patient Safety Network
The Institute of Medicine's landmark "To Err is Human" report
National Patient Safety Foundation
Joint Commission International Center for Patient Safety
The Leapfrog Group
National Quality Forum's"Safe Practices for Better Health Care"



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