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In absence of accurate way to track medical errors, TEDMED panel ponders what’s to be done?

The heartbreaking story of a young doctor recounting the medical mistakes she observed as a first year medical school student looking after a mother being treated for cancer reads like a  worst case scenario. It didn’t matter that it was a nationally ranked hospital. Almost anything that could go wrong did go wrong. But one […]

By Stephanie Baum on January 11, 2013

The heartbreaking story of a young doctor recounting the medical mistakes she observed as a first year medical school student looking after a mother being treated for cancer reads like a  worst case scenario. It didn’t matter that it was a nationally ranked hospital. Almost anything that could go wrong did go wrong. But one of the critical insights Dr Elaine Goodman took from the experience was the importance of being able to track errors and communication, among other things.

A TEDMED panel discussion on Eliminating Medical Errors left me thinking that’s not readily available now but produced several insights developed from working in healthcare settings.

John Nosta, executive vice president and  senior strategist at Ogilvy CommonHealth Worldwide moderated a panel that included Dr Thomas Gallagher, a professor of medicine, bioethics and humanities at University of Washington School of Medicine; Paula Griswold, the executive director of the Massachusetts Coalition for the Prevention of Medical Errors; and Dr. Michael Victoroff is the chief medical officer at Lynxcare.

1 There will never be no medical errors, but getting perspective is critical

Although panelists agreed that the industry has improved since the Institute of Medicine’s landmark 1999 report on medical errors, with more providers interested in trying to identify mistakes or near misses and the reasons behind them, the industry still has a long way to go.

2 There’s no such thing as an accurate statistic on medical errors. Victoroff’s response to the well meaning question on the subject from Nosta made a really interesting point — the lack of industry transparency means medical errors are tough to track beyond regional organizations that track that data.

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“How would you establish a trend for something you couldn’t even establish a few years ago? How many craters are on the dark side of the moon? We don’t have a baseline…I think the original Institute of Medicine number was a fantasy. We don’t have a uniform language to discuss and compare [errors]…The [Centers for Disease Contro]l could tell me who has influenza but they can’t tell who is making errors.”

3 Move beyond punitive culture and lack of systems knowledge. Younger doctors (ie residents) are more likely to talk (and therefore learn from) medical errors than physicians on the advanced side of their careers. That’s because older doctors are more concerned about the blame game.

 

4 Need more physician engagement in patient safety Gallagher observed that the lack of physician engagement in patient safety has been a critical problem and has been holding the industry back. The organizations that are doing this really well are where the message of physician engagement is coming from the top. In these cases, senior leaders are showing by example how much they care about safety – that it’s their number one problem to solve.

5 Better communication Technology may not be a cure-all, but one piece of technology Victoroff decried was too often underutilized was the telephone. As one panelist noted, it’s unethical to be silent in the cockpit. Teamwork makes all the difference, too. But you need both.

6 Talk to your patients Griswold made a critical point on making patients feel comfortable enough that they can talk about or raise questions about their care. “A key challenge in safety is we don’t have to solve it ourselves. There is a tremendous learning experience by talking to patients. The burden is always on the system to make things better for the patient.”

 

7 Transparency is important One medical student asked about the best way to avoid medical errors. Gallagher said, “Understand the importance of transparency. The  normal instinct when things go wrong is keep it to yourself. But when you make the decision to talk about it, that is a critical step.”