Medical Errors: There are more than you think

By John Milne on Thursday, February 6, 2003.

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Americans hear every day about medical progress … a cure for a new disease or a successful treatment.

But what doctors and officials haven’t been talking about is a surprisingly large number of medical errors, some of them causing injury or death.

This year, doctors, hospitals and state legislators are taking steps to reduce the number of mistakes.

NHPR’s John Milne filed this report.

A cancer patient in one of New Hampshire’s major hospitals can tell when a chemotherapy infusion is coming: The pharmacist and the nurse both wear protective clothing.

They look like they’re handling toxic chemicals – which, of course, is an exact description of chemotherapy.

Those chemo agents are designed to kill human cells – the cancerous ones – before the cancer kills the patient.

Before the medicine is plugged into the tubes connected to the patient’s veins, nurses make a final safety check.
They use a technology that’s as familiar as the corner store.
Conley/track 1/5:55
We bar-code all of our medications.
That’s Joe Conley, Concord Hospital’s chief operating officer.
Before a medication is delivered to a patient, it’s checked against an order, entered into a computer by a pharmacist, so that the system will match up the dose and the medication and the patient’s name, so that the nurse knows when he or she delivers the medication, it’s the right medication, at the right time, the right dose for the right patient.

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Despite the precautions, accidents happen.
Every year or so, some one dies of a chemotherapy overdose. Too much chemo can stop the strongest heart. It can actually melt bone.
Because of several very public chemotherapy accidents, oncologists take particular precautions.
But accidents happen in all specialties ... more frequently than people might suspect.

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Witnesses told the House Health, Human Services and Elderly Affairs Committee recently that Harvard University reckons that there could be a million accidents a year.
Accidents range from an unintended needle prick to fatal mistakes
Annual death estimates range between 40-thousand and more than 90-thousand. No one knows.
There’s no statewide documentation.
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Some hospital administrators argue those numbers are too high.
But even with more conservative calculations, Representative Peter Batula, who chairs that health committee, characterizes the scale of medical mistakes as an “epidemic.”
Batula/Track 13/0:52 We think it’s epidemic. Any time you talk about a thousand cases a week in this country, we have something going on that’s epidemic style. Yeah, I use that word rather loosely, but with a lot of meaning.

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With the legislative leadership behind him, Batula is pushing a bill to study medical errors. It comes just as the new president of the New Hampshire Medical Society, Doctor Peter Forssell of Peterborough, has identified medical quality control as this year’s priority for his profession.
Doctor Forssell hopes to discover why errors happen and how to prevent them.
Track1/2:38: I think we need to carry this effort back to everybody who needs to be concerned about it so that the reporting gets done and the solutions get identified.

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A national organization, the Joint Commission on Accreditation of Health Care Organizations, is adding new safety issues to its yardsticks of hospital quality.
And the state Foundation for Healthy Communities, linked to the New Hampshire Hospital Association, has begun to work with hospital authorities to measure the effectiveness of treatment all over the state.
Mike Hill is president of the New Hampshire Hospital Association.
Hill/Track 6/0:14:
I think that anything that policymakers can do to be more knowledgeable about these issues is an extremely valuable thing to do. The worst thing to do is pass a whole lot of legislation without knowing what actually is the case. Putting a group together and trying to study it from scratch seems like a good idea to me.

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If there’s an epidemic, as Batula describes it, it’s because doctors and administrators made quality a secret. Concord Hospital’s Joe Conley:
Conley/track 1/ 1:36
I think, going back decades, no one had ever talked about error. Error connotes safety or lack of safety. No one ever wanted to talk about it.
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Doctors are trained to be in charge, to be the captain of the ship. But, says Conley, with that responsibility comes blame when something goes wrong.

Conley 3:00
So there is a culture, there is a training, there is a tradition, that it’s all on an individual’s shoulders. When my personal view is, that’s not tenable. There’s a system surrounding all of us, and you’ve got to look at the elements of that system when something goes wrong, because not any one of us controls every element of that system.
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Concord Hospital has tried to create what Conley calls a blameless environment, where participants can talk about problems and work out solutions … instead of worrying about punishment.

They’ve been somewhat successful.

While one national study estimates 7 mistakes – big or small – for every hundred patients, Concord Hospital reports 2 per hundred.
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One good way to make such improvements, Conley says, is for medical personnel to realize –and accept – that they are just as human as their patients are.

Conley/9:06
We can do great good, and that’s what we’re here for, and we can do great harm. You’ve got to understand that, and you’ve got to have a healthy respect for that, a healthy respect for the risks in a very complex system.
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Legislative leaders say they haven’t yet encountered any opposition to Batula’s study bill.

For NHPR, this is John Milne.