MEDICAL MISTAKES -
WHY CAN'T WE SEEM TO LEARN FROM OUR MISTAKES.
In 2006 three babies in Indianapolis died when they
received adult doses of heparin, the same mistake happened at the same hospital
5 years earlier. Recently new attention has focussed on the exact same thing.
This time in Los Angeles with the twins of actor Dennis Quaid. Why can't we
seem to learn from our mistakes.
Welcome to the Clinician's Round Table¸ I am Dr. Leslie
Lundt, your host, and with me today is John Nance. John is a decorated
Military Pilot Attorney, Global Airline Safety Expert and one of the Founding
Members of the National Patient Safety Foundation. He is the author of the
recently published "Why Hospitals Should Fly: The Ultimate Flight Plan to
Patient Safety and Quality Care."
DR. LESLIE LUNDT:
Welcome to ReachMD, John.
Thank you Leslie. It is good to be with you.
DR. LESLIE LUNDT:
John would don’t you fill us in on the heparin tragedies.
Give us the background.
Well, this is one of those things where we had a dress
rehearsal and then we had to repeat as you mentioned in Indianapolis with
tragic results for 3 babies, but we did not have a systemic way of really
informing the entirety of the medical world that Hep-Lock, the pediatric
version of heparin and heparin itself can easily be mixed up and the labels
were really the problem, but the fact was that even if the pharmaceutical
company had not taken or did not and ultimately did not until after another
tragedy make a move to make those more different. The fact is that the medical
profession itself had no method of communicating universally. In aviation,
just to give you an example and I know aviation is just one of several
industries like this that can do it, but aviation stands out because if we have
a problem with for instance a Boeing 737 this afternoon. By tomorrow morning
every operator of a 737 on the planet will know what the problem was and how if
we do have an answer, how to solve it. Now agreed that is an individual
machine. We are talking about human beings, but human beings are very similar
and we do have a responsibility to make sure that we do not have to have 15 or
20 or 1000 deaths from the same cause like for instance undiluted potassium
chloride left on a unit in undiluted fashion, which eventually will get
injected and stop a heart. That was hit list #1 item for the joint commission
a number of years ago because we killed 1000s before we realized that needs to
be pulled off the units. Now in the case of heparin and Hep-Lock, the Dennis
Quaid case was a repeat of what happened in Indianapolis and they had had
problems in the past with mixes of medication. In this case, there was not
even a picture symbol, but the medication got in the hands of the nurse, it was
the wrong stuff, it was the adult version, and it got injected. This must not
happen again, but it should never have happened a second time.
DR. LESLIE LUNDT:
How can we learn from how aviation has handled these sorts
of things. You know it seems overwhelming in your scenario that if we had a
Boeing 737 with something wrong to have it in everybody's hands the next day.
How realistically can we do that in a system so vast as a medical system.
Actually, a lot easier than you might think. If we have an
ability to give alerts in areas for instance in Pediatrics, there are specific
things just like this. Now, thanks to the fact that it was Dennis Quaid and
that he is a famous individual, most everyone in healthcare has heard about
this and that massage has now gotten around, but we need a method that does not
involve a near-miss or a tragedy involving a famous individual or their child
in order to make sure that for instance a doctor who comes in for an operation
on a particular day has a little list of alerts to look at very short, very
sweet, very to the point of things that might affect his or her practice. If
we have the ability to share our information outside awaiting for lawsuits to
bring it out which sometimes takes 10 years. We can change this thing very
rapidly. The second part is we still have this approach that there is a root
cause to every problem. Well there is no such thing as a root cause and a root
cause analysis. As root cause is, there is never just 1 reason for a medical
mistake that impacts a patient or could impact a patient. If we look at all
the things that contribute, we will fix systems much, much more rapidly than we
do now and for instance if it is not just a matter that a nurse made a mistake,
but all of the things that supported that mistake, we can probably interdict 15
other mistakes in the future that are dissimilar in terms of their final impact,
but had the same causation pattern. In other words, problems with the
pictures, problems with the medication chain, problems with communication,
every accident or incident has a unique chain out of which we can derive all
sorts of things that need to be immediately altered.
DR. LESLIE LUNDT:
But who has the time to look at that complex set of events.
Well, of course, I could turn that around and say who can
afford not to, but in fact, the reality is that every hospital has a risk manager.
Many hospitals now have people who are responsible in a larger sense for
instituting safety and certainly we know since the IOM report in 1999 that this
is not something that can be bypassed or considered to be something your
quality program takes care of. So, whatever it takes and then boards who are
understanding this more and more as our CEOs that if they do not have an
infrastructure that can take care of looking at these items and certainly
extracting every possible piece of information from their own internal
failures, then they are continuing to put themselves out in a way that
certainly in the current legal system almost guarantees not only a tragedy for
the patients, but a tragedy legally for the hospital. Because if anybody out
there thinks that the attorneys, the plaintiff attorneys do not understand the
latest cutting edge methodologies of communication problems and how to fix
them, etc., think again they certainly do and we just don’t have the luxury of
time in medicine to sit around and wait for something to develop. We have got
to take the aggressive steps to take the information from each and every
accident, a near-miss, etc., and repair the system. Whatever it takes is what
we have to do.
DR. LESLIE LUNDT:
But in order to do that don’t people have to admit that
there was a mistake.
Well that's another fascinating area. First of all the
cultural change that has to occur here is going to probably take 20-25 years to
be fully realized. Now that doesn’t mean we can't change things in a
particular hospital in 3-6 months. You just have to maintain your hand on that
throttle of change for a long period of time, but what happens here is also a
process of learning to say and I teach docs to do this and they are much the
better for it as they will tell you afterwards just like I had to as a captain,
an aircraft commander in the Airforce. I had to learn to stop saying I am a
senior leader, so therefore I am perfect and be a leader by saying you know I
am very good at what I do. I am a very good doctor, I am very good aircraft
commander, but I am a human and I am incapable of being perfect. I very seldom
make mistakes, but when I do, my pride is in knowing that and in being ready,
willing, and able to take that mistake and publicize it so that nobody else
will follow down that same path including me. Now that takes a lot of courage,
but that is the world that we are now creating and where we create it, we have
people who are eager to exchange information about things that went wrong, so
they can make them not go wrong again, bad English, good concept.
DR. LESLIE LUNDT:
If you are new to our channel, you are listening to the
Clinician's Round Table on ReachMD XM-157, the Channel for Medical
Professionals. I am Dr. Leslie Lundt, your host, and with me today is John
Nance. You were discussing medical mistakes.
John, one of the most incendiary statements in your book, at
least to me was that we should all assume that meds are lethal until proven
otherwise. Tell us about that.
Well, when you look at as I have thousands of medication
disasters. In almost every incidence, there is an assumption, well back to
those 3 assumptions, communication and perception. We have an assumption that
the medicine that that nurse is taking to the bedside is the right medication,
the right dose, and she is getting ready or he is getting ready to put it in
and the right method of application every time. Now, when you time that
assumption around, if we could do it, if we could change the assumption, we
would cause another check, another level of concern to be there each and every
time and in so many, many, many cases that would have made the difference. I
can't tell you how many of these reports end with a nurse having said you know
I had a feeling something was wrong, but I did not have any validation of it
and I was………..Incomplete dictation