Talking the Talk. Time for Walking the Walk?
Barry Beith / MedicalIn 1998, the Institute of Medicine (IOM) conducted a study of healthcare in America. In their published report of 2000, entitled “To Err is Human,” they reported that at least 98,000 deaths occurred annually in U.S. hospitals primarily due to infections, diseases, and medication errors that resulted in avoidable death. Avoidable death that was caused within the very healthcare system that was “dedicated” to saving lives and restoring health. All of us who read the report and two subsequent reports by the IOM were struck by the critical nature of this finding and the need to immediately address it.
The Consumer Union, in a report published in April of 2009, revealed that virtually no headway has been made relative to improving this statistic in the past decade. My response and yours should be something akin to “you have GOT to be kidding me!” Now, don’t get me wrong. I am aware that the healthcare system is complex and made up of thousands of “Mom and Pop” collaborators that must interact and cooperate and remain profitable, but pppuuullleeeaaasseee! When hospitals conclude that paying hush money is preferable to solving problems and paying for efforts to NOT kill patients, then the problems take on an air of criminal neglect of such magnitude that Congress itself needs to step in.
The problem is not just with the Walter Reed’s of the world or other VA institutions wherein we must choose between doing the right thing by our vets versus buying a new weapons toy, but even venerable institutions such as Duke Medical Center, Cedar Sinai, and the University of Virginia Hospital are cited for errors that can and must be eliminated. Notable and high-profile problems with heparin, tainted surgical tools (in over 3600 surgeries across three years), and multiple deaths potentially due to mistyped donor organs are pervasive, and yet hospitals continue to conduct business as usual.
Tools for identifying and correcting human errors or, at the least, managing the resultant impact of such errors are available and do indeed work. This is a case of having the tools at hand. Why the hesitation? Maybe it is because of the difficulty in quantifying the ROI associated with events that do not happen because the intervention worked. Measuring the benefits of an intervention can be difficult, requiring an acceptance that errors would have happened had the intervention not occurred. The situation is analogous to the past administration trying to justify its expenditures and actions by alluding to the terrorist events that were precluded by their actions. There is a paucity of evidence…in fact, a complete lack of it. The very fact that nothing occurred in and of itself undermines the very evidence needed to justify the cost.
So how does one circumvent this illogical trap? One approach is to aggregate the costs associated with the class of problem both prior to the intervention and after the intervention. Since there are no guarantees that the intervention will work, it requires an act of faith for the period of the intervention. Another approach is to estimate the probability and costs of certain events that will be found and corrected during the intervention. This again requires an act of faith to spend the funds necessary to identify and correct the problem to begin with, and perhaps the willingness to identify the problem, NOT correct it, and then see whether it occurs. This would be the “Jackass the Movie” approach to human error management.
Whatever the approach, the passage of most of a decade without addressing this problem represents the worst that healthcare has to offer and, certainly, does not fulfill the medical credo of “first, do no harm.”
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