Saturday, August 4, 2012

The Devil Is In The Details

The US Institute of Medicine estimates that somewhere between 44,000 and 98,000 deaths in hospitals annually are due to medical errors Rachel Giese.  Most of these errors are preventable. 

But the modern hospital confronts elements that make it a veritable breeding ground for poor outcomes.  

Poor judgement on the part of doctors is an issue that requires attention but it is not pivotal.  The most pressing problems have much more to do with faulty operation systems, poor communication and the complexity and severity of today's hospital admissions.

For example, rather than being cared for by his/her family doctor, in this era of 'shift medicine', a patient is cared for by a number of hospital based physicians, who devote their time solely to outpatient care.

The personal physician's deeper Insights into the medical and social aspects of their patients' lives are more or less lost in the fracas of acute hospital care.  The communication between the hospital doctors is often done on the run causing changes, distortions and misinterpretations of the original message. Misunderstandings abound.  

Operational breakdowns abound too.  Just consider the number of departments (nursing, nutrition, mental health, speech pathology, social services, pharmacy) and consultants who regularly interact with patients and each other.  These caregivers appear not to have a lingua franca  and, as a result, frequently trip over each other. 

While team care has its merits it oftentimes looks like a bee hive without a queen bee. 

A queen bee is critical in medical care because she assures the kind of order, and ritual, necessary for safe outcomes.

Good care is not sexy, it is methodical.

The airline industry has famously recognized this and has reduced its fatality rate to nearly zero.  They didn't accomplish this with better pilots. They did it with check lists.  

On all flights it is required that the pilot and co-pilot evaluate together a list of safety questions.  It's the same form and the same questions every time.  Are the flaps up ( should they be)?  Is there ice on the wings?  Is the landing gear ready to go? 

The US Institute of Medicine and progressive hospitals have embraced  the checklist idea with many thousands of errors and deaths reduced annually.  The operating room list asks the team to review, among other things, the patient's identity, the nature of the operation, confirming, for example, that it is the correct kidney to be removed, skating clear of an intolerable 'oops'.

Another beneficial list deals with the placement of central venous lines, a major source of hospital infection, morbidity and deaths.  When they are placed willy nilly, going on instinct, based mostly on personal experience (often limited), errors soar.  Following the proven and battle tested lists technique can bring the error and complication rate to near zero. 

It seems inevitable that many more lists will be brought into hospitals and clinics.  Ones to eliminate errors in medication dosing at discharge are especially needed.

Doctors generally take a dim view of lists, at first blush, regarding them as an assault on their clinical hegemony.  Most are converted, however, by superior outcomes and a realization that clinical judgement remains an indispensable element of medical practice.

But clinical judgement will increasingly be sharing the spotlight with computers in what should be a promising relationship. 

Airlines have once again led the way, demonstrating that aircraft facing dire circumstances are sometimes more likely to escape disaster when following the dictates of the inflight computers rather than the most experienced pilots.

How could this be?    

The pilot may be sleepy, or hungover, or depressed.  The computer is not.  The pilot may be seasoned but unable to match the computer's storehouse of information dealing with successful or failed maneuvers in historically similar circumstances.

Going on automatic pilot then, checking the details and following repetitious patient care plans on the medical wards and operating rooms may not be scintillating, but doing so adds greatly to safety, reducing  both errors and mortality.  And not to worry, the importance of clinical judgement, wisdom and compassion will remain the most valuable coins of the realm.

So looking for a hospital?  If they have central line and operating room lists they are probably committed to safety and deserve your confidence as the days of do it my way, swashbuckling medicine are increasingly numbered.

In short, the devil remains in the details.