What we fail to talk about when we talk about medical mistakes: time pressure

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I find pseudoscience anathema, but that does not mean that I am apologist for contemporary medicine.

I am quite critical of some aspect of medical practice. The subject of medical errors has particular personal resonance for me as my father died at age 60 in the wake of a major medical error that occurred at the hospital where I was on staff and which my professional colleagues tried (stupidly and unsuccessfully) to hide from me.

So when I read papers like the recent BMJ piece Medical error—the third leading cause of death in the US, it makes me angry and frustrated in equal measure that the problem has not gotten any better in the nearly 30 years since my father died.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]The relentless emphasis on performance metrics forces doctors and nurses to care for ever more, ever sicker patients in ever less time.[/pullquote]

But I’m also concerned that we are missing something important. When we talk about medical errors we fail to talk about the role of the relentless emphasis on performance metrics that force providers to care for ever more, ever sicker patients in ever less time.

In the last few decades we’re witnessed an extraordinary change in the delivery of medical care. Medicine, typically viewed as a profession guided by elaborate professional ethics, became a business. We let it become a business, indeed we encouraged the change, because we thought it would save money. It’s not clear that much money has been saved, but it’s very clear that the nature of medical care has changed dramatically.

Forty years ago, most people had family doctors that they knew and who knew them and worked directly for them. They were admitted to the hospital early in the course of an illness and stayed until they were nearly fully recovered. Many diseases now successfully treated with elaborate high tech methods couldn’t be treated at all.

Now, in contrast, patients are forced to change physicians frequently as they change jobs or insurance. Doctors work for large corporations who make demands on them that aren’t always in the best interests of patients. There is tremendous emphasis on keeping patients out of hospitals, and when admitted sending them home quicker and sicker. Doctors have no control over the number of patients they are required to care for and may receive bonuses for moving ever more patients through the system ever faster. They waste tremendous amounts of time justifying their medical decisions to functionaries whose only goal is to avoid paying for expensive care.

Nurses are under similar pressure to be more “efficient.” Patient loads have been increased so that a nurse who might have been responsible for 5 patients in various stages of recovery on each shift are now responsible for 6 or more very sick patients, all in need of elaborate monitoring and complicated medical care.

Both doctors and nurses are constantly prodded to care for more patients, and sicker patients, in less time than ever before.

The error that preceded my father’s death was an administrative error. No one told him that a routine pre-op chest X-ray done before minor surgery showed a cancer in his chest since everyone thought someone else had already told him. But there are a limitless array of medical errors, including medication errors, surgical errors, iatrogenic complications and more.

How deadly are they? According to authors Makary and Daniel:

… We calculated a mean rate of death from medical error of 251 454 a year using the studies reported since the 1999 IOM report and extrapolating to the total number of US hospital admissions in 2013. We believe this understates the true incidence of death due to medical error because the studies cited rely on errors extractable in documented health records and include only inpatient deaths. Although the assumptions made in extrapolating study data to the broader US population may limit the accuracy of our figure, the absence of national data highlights the need for systematic measurement of the problem. Comparing our estimate to CDC rankings suggests that medical error is the third most common cause of death in the US. (my emphasis)

This is just an estimate since there is no standard for keeping track of medical errors. Lest you think this is a US problem, the authors point out that both Canada and the UK have a similar problem.

Makary and Daniel offers suggestions for dealing with deadly errors, summarized in the graphic below:

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These suggestions include making errors more visible so we can understand the dimensions of the problem, making remedies available and creating a culture of safety by engineering more fail safe measures into the delivery of medical care. We might start by acknowledging that the provision of safe medical care requires TIME.

We have elaborate rules for airline pilots that involve strict limitations on how long they are allowed to work and what they are required to do during that period. What would happen if we insisted that pilots, instead of flying one plane at a time, should be responsible for flying multiple planes at a time AND supervising dozens of others who are also flying planes at the same time? Would we be surprised to find pilots making deadly errors in those condititions?

Yet we have no problem forcing nurses to care for ever greater numbers of ever more seriously ill patients at one time. Should we be surprised that they make errors?

We have no problem increasing “patient panels,” the number of patients a doctor is require to take on, by 10, 20 or 50%, expecting them to be able to provide the same level of care to each patient in a much shorter period of time. Should we be surprised that they make errors?

We have no problem forcing doctors to spend endless hours on phone calls and paper work attempting to get reimbursed for work they have already done, or attempting to get permission for care that they want to deliver. Should we be surprised that they make errors during ever shorter patient appointments?

In forcing doctors and nurses to be more “efficient,” have we made them more prone to errors?

I don’t know the answer to that question; I don’t think anyone knows. It seems to me, though, that if we want to take steps to reduce deadly medical errors, answering that question would be a good place to start.

  • Liz Leyden

    I finished nursing school in 2008, just before the economy collapsed. The shortage when I started school was a glut when I finished. No one wanted to hire new grads. I never wanted to work in a nursing home, but after 10 months and a cancelled job (plus a spouse who refused to move and a mother who was diagnosed with cancer 2 weeks after I graduated), my only job offer was in assisted living, 250 miles from home. I had 25 residents. After a year I bounced to what turned out to be Nursing Home Hell. I ran screaming after 6 weeks.

    I knew I had to get out of long-term care when I had a young newly-diagnosed diabetic who needed to be taught to check her blood sugar and give herself insulin. She was one of 17 residents. It took me about 10 minutes to teach the first time, and the entire time I thought “will you please hurry up! I have 16 other residents!”

    In long-term care I had 15, 17, 25, and (for one nightmare overnight shift), 60 residents. The 60-resident shift was my last shift in LTC. If I hadn’t gotten a job (with a significant pay cut) in home care, I would’ve left nursing altogether.

  • It seems to me that there’s more going on than the desire to “merely” save money. That’s part of it, sure, but not the whole of it. The sheer amount of knowledge has grown to the extent that specialization has become inevitable so patient care has become fragmented, sometimes with dire results. The working model for nurses was changing even during my training, with the registered nurse (just beginning to become “academically” educated) changing from the primary caregiver at the bedside to the “team manager” where her “advanced” education made her more “effective”.

    This was brought home to me during my mother’s terminal illness in 1980. Having gone to the hospital directly from the airport, I discovered my mother, at 2 pm, looking uncomfortable and disheveled. Despite protests, (“the nurse’s aide will give her “a.m.care” directly”) I got some linen and proceeded to give her a bath and change her sheets — and discovered, when I turned her to give her a back rub, that she had a large and deep decubitus ulcer on her back. I called the RN to see it; she was completely unaware. Of course not; all my mother’s care had been done by the aide, who had thought it a manifestation of Mother’s illness, not worth reporting. The RN had been in only to give meds — this was “division of labor”, the aide not being permitted to do this. Giving a bed bath was thought to be not an efficient allocation of labor for a highly trained RN when an untrained aide could do it just as well.

    • DelphiniumFalcon

      Holy crap! I hope that nursing assistant got fired and put on the abuse registry for neglect! I mean yes it may annoy the nurse but basically the first thing I learned in my CNA class is to document even tiny details and report any skin changes to the RN. The RN teaching my class had a similar situation happen with her father so she harped on it pretty hard. I’d rather be annoying than neglectful.

  • BeatriceC

    Middle kid update: He’s lost a pound and a half since hospital discharge. That could be the difference between having just eaten when he was weighed for discharge and lunch being delayed for his appointment today, so I’m not worried yet unless a trend starts. His pediatrician is going to try to get nutritional supplement drinks covered by my insurance (and his office manager is the most awesome person ever…if she can’t get it done, it simply can’t get done). Boost/Ensure/etc drinks are really expensive, and it’s stretching my budget, so that would take an amount of stress away if it could be covered.

    Doctors also asked for as complete of a family history as possible. I could do that for my side of the family, but really had very little memory of my ex-husband’s family. I haven’t spoken to my ex-husband in 13 years (exactly 13 years on Wednesday, as the last contact was the oldest boy’s 4th birthday and Wednesday is his 17th birthday). I didn’t really even know how to find him, but the wonders of Google produced a pretty good bet on an employer. I called said employer and left the craziest message ever, which was just “If you happen to have a *his name* working there, I need to get an important message through. I’m his ex-wife and one of his kids is extremely sick and I need family medical information from him. If this is the right person, please have him call me back”, and then I gave MrC’s cell phone number, because I was leery of giving him my own. Much to my surprise, he called back within 5 minutes. It was awkward to say the least. I’m reeling from the conversation. It seems my divorce wasn’t what I thought it was and my parents are more evil than I thought. I’m really trying to take care of myself, but my emotional state is just not good right now.

    • PeggySue

      I can’t imagine things getting worse than they have been with your son so ill. Very sorry. Do take care of yourself.

      • BeatriceC

        Right now it’s just the realization that my parents took advantage of the fact that I was sick trying to stay pregnant with the little one, then recovering from a delivery that was done so early in an effort to save my life, to actively sabotage my marriage. He certainly could have made different choices, but as I’m currently living 3000 miles from my parents and have zero contact with any member of my family in order to get away from them, I can completely understand being afraid of them. I feel guilt for the years of misplaced anger and am somewhat in mourning for what could have been. The actual events happened years and years ago, but this has brought all those emotions back up.

        • Who?

          Given what you’ve said about your family, and based on some experiences I’ve been a witness to over the years, I had wondered if they may have had more of a hand in the end of your marriage than you perhaps thought. Outrageous and arrogant behaviour.

          Sorry about the boy, hope the weight loss is a blip not a dip.

          • BeatriceC

            Looks like they did. Apparently he was told that I didn’t want to see him. I was far too sick to even begin to make those sorts of decisions. Remember the little one was born to save *my* life, as pre-eclampsia and HELLP syndrome was moving quickly towards full blown eclampsia. He had no idea that had happened. They were lying to him about me and then lying to me about him, while threatening him that they would take the kids from both of us if he tried to contact me. They’re extremely wealthy so they can get away with that kind of crap. I fled for that exact same threat so many years later, so I can completely believe that happened. One of the things I’d been so angry about was a snippet of a conversation I’d overheard, which sounded cold and callous to me, which was apparently a sarcastic comeback out of anger towards my father. Honestly I feel like shit right now. But I can’t go back and change it. It’s just more damage and destruction caused by my parents, and all I can do is my best to help him make up for lost time with the boys. Not sure how I’m going to do that, as they’re pretty emotionally fragile right now.

          • The Computer Ate My Nym

            I’m sorry for all the losses you experienced. Please remember that this was not your fault. You did the best you could with the information you had. Your parents’ evil is not your fault.

          • Who?

            I’m sorry. There are a lot of very damaged people out there who behave disgracefully. The money helps but it isn’t a prerequisite and this kind of vicious manipulation does happen without it.

            To echo CAMN, this is not your fault, at all. You did what you could with the information to hand, and had no reason to know you were being handled.

            Let’s hope the boys are able to reconnect with their father.

          • Amazed

            I’ve seen much evil wrought by well-meaning parents into their children’s marriages. I’ve been wondering about yours – who don’t even seem well-meaning. Honestly, I am not surprised. It’s so common. You were just one of the many who tried to do their best and it looks like your ex-husband did the same. Do take heart from this.

            Fingers still crossed for your boy and you!

          • FormerPhysicist

            You’re a good person, and I’m sorry about more upset on top of everything. Yet, it’s wonderful he came through and you got the info you need.

          • DelphiniumFalcon

            You’re a very mature person for handling this the way you are and incredibly brave to be willing to track down your husband with the history you have all for your son, regardless of how your parents twisted your perception.

            To echo what everyone has said please do not ever blame yourself for what happened. Your parents took advantage of both of you in a very stressful and emotional time and it was despicable they used it.

            Please don’t feel guilty. The more you talk about them the more they remind me of my grandmother, the one I’ve mentioned a few times that’s emotionally abusive. She’s ruined or tried to ruin several of her kids’ marriages and very nearly destroyed my parents’. Even after twenty years of them being married she took advantage of my mom, when she was sick, to try to manipulate her into leaving my dad. Just because she didn’t like him and was pissed my mom didn’t marry the guy she had picked out for her. Your parents wouldn’t have stopped trying to destroy your marriage even if they had failed at the initial attempt if I had to guess. Not every marriage can survive such a toxic influence. A lot don’t. I don’t think it makes the people who can’t make a marriage survive that any lesser. And a lot of times the marriages that do survive end up incredibly dysfunctional.

            Since he’s been so open to communication I think he has an idea of what really happened and doesn’t blame you. I could be wrong but either way it’s in the past and you’ve both created your own lives. My uncle and his ex-wife still can’t have a civil conversation and it’s been about fifteen years since my grandmother tore them apart. I don’t know that either one could do what you did and risk opening old wounds just for the chance that something might explain a child’s illness. You’re such a strong person and mother for doing that. You deserve praise and not guilt. Perhaps mourning what could have been but not guilt.

            You’ve also done what a lot of people in these parent/child abuse situations never do. You left and protected your children. Picked up and put as much distance between you and them as possible. That’s terrifying. And you did it and stuck to it. I still watch my mom get beat down by her mother. She stood up and put her foot down on the emotional abuse in a meaningful way for the first time only last week and she’s in her mid-fifties. And I believe my mother is a strong person. You have to be some kind of super woman to have done it so young.

          • BeatriceC

            I’m definitely not super woman, though I appreciate the compliment. It means a lot right now, feeling as low as I have been. I have my own struggles. MrC tells me of horrible nightmares and flashbacks I flat out don’t remember. He’s recorded a few of them. They sound like something out of a horror movie, with me crying and screaming in fear of something, though he can’t figure out what. He says I wake up confused and not knowing where I am, thinking it’s years ago (different times though), then I go back to sleep and wake up in the morning and remember nothing about what happened overnight. He says the last two nights those nightmares and flashbacks have ramped up in intensity 1000 fold. I guess I just get done what needs to get done during the day, and then all the crap I’m suppressing comes out at night when I’m sleeping. I wouldn’t believe him except that he’s had the presence of mind to audio record a few of them.

          • Irène Delse

            It’s amazing sometimes how our brain manages to cope. And find strength in unexpected places. But it sucks to have to learn this the hard way. Hang in there! And it goes for MrC too.

        • guest

          I am so sorry you had to find this out in the middle of an already stressful time. But good for your ex for being able to put it all aside and call back promptly to give you the information you need.

        • Valerie

          I’m so sorry you are going through this right now (or ever, really). That must have been hard just to track down and call your ex, and then to have this piled on top of it all… that’s a lot.

          • BeatriceC

            I spent a good hour before the call and a good half hour after the call puking my guts out. It was not pretty. But my kid’s health is more important that a little discomfort on my part, so I did it.

        • PeggySue

          Heartbreaking. And very stressful. I am glad he gave you the information you needed, and am thinking of all of you.

        • Kelly

          I am so sorry. When it rains, it pours. At least he was willing to help you and your son. Thank you for the updates as well.

    • Angharad

      I’m so sorry. I was thinking about you and your family today and hoping that things would start looking up soon. I hope you are able to find peace and that your son’s condition improves.

    • Inmara

      Thinking of you and your family, hopefully kid’s weight gain will resolve and you’ll have a time to catch a breath for yourself again!

    • Mishimoo

      So, so sorry that they messed with you all so much. That is absolutely disgustingly vicious. Look after yourself, and I hope middle kiddo gains weight again soon. Also hope you get some damn good news soon, you deserve it.

    • An Actual Attorney

      I’m so sorry for all you are going through. I hope the information from your ex helps the doctors figure out what to do. And I hope you remember to care for and forgive yourself.

    • demodocus

      oh, for the love of little green apples. Finding that out would have been a shock without an ill kid. *hugs* for you all and i’m glad your kids’ father is a better person than you had thought, even if your parents are not.

    • Dr Kitty

      I’m thinking of you all.
      You seem like such a strong, lovely person and I’m so sorry all of this is happening.

    • Charybdis

      Oh, damn. That is truly an awful situation, all the way around. Can Middle Kid handle something like yogurt, pudding or a smoothie? I know that they don’t have the “complete nutrition” profile like the supplement drinks do, but they might taste better. Those Slim Fast shakes taste WAY better when blended with a scoop of ice cream (don’t ask how I know this). Or a container of the instant breakfast stuff. I’m just trying to think of possible alternatives to the food issue, so feel free to tell me to STFU about it, if you currently can’t deal with One. More. Suggestion. from someone.

      I am so sorry that all this has avalanched onto you and I wish there was something concrete I could do for you and your family, instead of just sending sympathy and good thoughts for all of you. Hang in there, please keep us posted on how things are going and feel free to vent; I promise we will listen, commiserate and not think badly of you. =)

      • BeatriceC

        The office manager at the pediatrician’s office is trying to get insurance to cover them. Also, the school counselor at the youngest kid’s school (who also happens to live 3 houses up the hill from me), is looking into resources to help pay for them as well.

        And I might be venting a lot in the coming weeks, so be warned!

    • moto_librarian

      Just what you need on top of all of the stress of worrying about your child. I’m so sorry that you have to deal with these assholes. If you’ve ever doubted your decision to leave your family behind, you should feel quite validated right now.

      • BeatriceC

        Yup. If I had any doubts about doing what I did, I don’t have them anymore.

    • Irène Delse

      This internet stranger is appealed at such a development, gladly offers virtual hugs and wishes for the best.

    • D/

      I’ve found you all coming to my mind during all this. I’m so sorry for everything you’re going through. Please continue trying to take care of yourself.

  • Margo

    I am on a roll now….when I first went into nursing and then midwifery, patients had one set of notes, where everything was recorded. Now we have a system where especially in midwifery, the patient has hospital notes, midwifery notes, well baby notes, antenatal notes, labour and post natal notes, two copies thereof, hospital and midwifery, then there are hearing test notes, discharge hospital notes, discharge midwifery notes, GP letter/referral letter, well child booklet, immunisation referral, the list goes on, all separate bits of paperwork, that takes an age to fill out. It has been proven that all this documentation has not decreased error, in fact the opposite is the case, for every minute set aside for all this doubling up of information and the forms to be filled in for reimbursement for work done is time away from the patient, how does that make good sense? Since the health system became driven by those that govern to be more cost effective patients and patient care has been under threat.

    • Who?

      When I was pregnant (UK, early 90s) I think we held our notes and carried them to all appts and even I think out and about in case something happened and they were needed. Then to hospital for the delivery.

      • Inmara

        We have this system in my country (it’s called Mother’s Passport) – all the antenatal tests and notes are in one document which is brought to hospital. Things get complicated after discharge because pediatrician and GYN notes are not linked with hospital anymore (and if baby gets readmitted to different hospital they don’t inform hospital of birth as well) and thus it’s impossible to properly evaluate birth outcomes case by case.

        • Who?

          Interesting-my notes stayed at the hospital where I delivered, from memory. I think the babies’ notes-maybe a copy?-went to the GP/health visitor records.

          • Inmara

            Upon discharge I was given a summary note of myself and baby (mode of birth, Apgars, weights, administered medicines Etc) but the original package of documents stayed at hospital.

        • SporkParade

          Huh, I wonder if that’s why our pediatrician told us to take our newborn to the hospital where he was born for a medical procedure. So that they would already have his records.

      • Dr Kitty

        Which is great… Provided the woman remembers to bring her notes with her. Not everyone does, and, because they are paper notes, there is no back up.
        Trying to work out if a BP reading is normal for someone requires access to previous BP readings, for example.

        The hospital is also meant to post me a copy of the discharge summary for mum and baby- mode of delivery, complications, birthweight, blood loss, last BP, length of labour, all that. Usually I like to have a quick look at it before I see women for their six week post natal appointment.
        Increasingly, the letters are arriving AFTER six weeks.

        I don’t know about you, but if someone had a 48hr labour, pushed for 4hrs, had failed forceps and a crash GA section with a PPH and a baby that had low APGARs, you want to know about it before they turn up six weeks later, traumatised and exhausted and burst into tears when you say “I’m sorry, I don’t have the letter through yet, tell me about the birth!”

        • Bombshellrisa

          My OB practice is paperless and everything from the hospital chart goes into my patient file, so presumably everything is there to see. And at my six week appointment, they still asked me about the birth, how long I pushed, ect. I was actually off about everything because I wasn’t sure what time we checked in, and how long I pushed.

    • Old Lady

      I was watching a nurse being being shadowed/taught the last time I went to see the Dr at my hospital and I remember thinking it looked pretty ridiculously complicated. One thing I love about them is that they ask you what is the preferred method of information delivery and so I get little summary handouts of my visits which are great and I’m glad to be able to refer to them.

  • Margo

    just a week ago my family were receiving care in the maternity hospital for a rare complication. It struck me how under pressure every member of the obstet team were. It was hard to watch the tiny obs reg juggle several cases at once, and whilst with us, his bleeped and cell going off, which was very distracting, the consultant was extremely busy also and the nursing/midwifery staff were rushed off their feet. One family member, not ever having worked in a hospital commented that obviously this was a very busy day….sadly, as an insider, I knew this not to be the case. Every day in our hospitals fantastic practioners are required to make life saving /changing calls re appropriate care for those patients in their care,whilst dealing with ever increasing demands from the number crunching brigade to be more efficient, more cost effective, work more hours than is reasonable or safe, and we wonder why error occurs? It is very disheartening.

  • Dr Kitty

    OT:
    A not very enjoyable complication of breast feeding- milk cysts.
    Because finding a breast lump is not fun, and leads to stress and anxiety.
    But at least it was easily fixed by a nice radiologist, a green needle and a large syringe.
    More excitement than I really needed though.

    • PeggySue

      Oooowwww

      • Dr Kitty

        You would think…
        But it was completely painless (he was very quick, and has been aspirating cysts longer than I have been alive).

    • Nick Sanders

      I’m afraid to look that up. Would that be a cyst filled with milk, or just a cyst on the mammary glands caused by lactation/hormones?

      • Dr Kitty

        It is a milk filled cyst.

        • Nick Sanders

          That’s what I was afraid of. For some reason that’s grosser to me than a normal cyst filled with lymph fluid or whatever.

          • Dr Kitty

            The problem is that it just feels like a hard, non tender lump, you need ultrasound to show it is fluid filled, and aspiration of the fluid to prove it is milk.
            So even though my rational brain was all “this is probably a milk cyst or a simple cyst, or a fibroadenoma” my lizard brain was panicking a bit.

  • DelphiniumFalcon

    So I’m curious to hear from people that are the most highly impacted by things like Zero Harm initiatives, the medical staff that already has so much to pay attention to.

    Do you think things like Zero Harm that the Studer Group is encouraging actually helps or is it all just buzzwords and feel good fluff that doesn’t accomplish anything?

    https://www.studergroup.com/hardwired-results/hardwired-results-16/the-last-word-getting-to-zero

    • CandiO

      Feel good stuff is what it seems to me. I can solve every safety issue, best practice problem, quality initiative, what have you in two simple words: more nurses. Actually hire enough staff to do the work and you won’t have to creatively think up “solutions” to your hospitals problems.

      • Dr Kitty

        When do people make mistakes?
        When they are tired, hungry, angry and distracted.
        A situation almost guaranteed by most of the current systems.

        • The Computer Ate My Nym

          Not to mention stressed. Like, for example, when they are working essentially under threat of being punished if they make a mistake. Which they are likely to, being tired, hungry, etc.

    • Mishimoo

      The library I am doing my work placement in has a Zero Harm policy in place. I was expecting it to be all buzzwords and not amount to very much at all, but they actually take it very seriously for all of the joking that happens. I’ve had OH&S briefings on everything, and when I had a sore wrist from an injury outside of the workplace, I was barred from certain tasks until it healed. I was expecting frustration/irritation, but everyone was really relaxed and nice. I think it can work in the medical fields but there needs to be a cultural shift, and expectations need to change.

    • Sue

      The concept of “zero harm” is both naive and potentially harmful.

      I’m not saying we shouldn’t strive continuously to minimise avoidable risk where it is feasible to do so, but we also have to be aware of a few key principles:

      – There is no aspect of life that is risk-free. Not even eating or breathing. Or cooking. Or travelling in a car. Even sleeping.

      – Then, we must be aware of the range of side-stream harms that can come about when we try to reduce risk in one specific area. It can be like a balloon – push in one part, another pokes out.

      – Third, all health care provision involves compromises – though some areas more than others. We can minimise risk for one person by depriving 100 others of their access.

      – Fourth, we have an increasingly risk-averse population with high expectations, as longevity and treatments improve. The health care errors are not concentrated in the healthy young, but in those with complex or ciritical disease.

      So, we can make anesthesiology zero-risk by refusing to put anyone to sleep, but then people will suffer for not getting surgical treatment.

      We can make emergency medicine zero risk by closing all the EDs, but then people will die due to lack of access.

      We can make obstetrics zero-risk by letting lay midwives manage all births – with consequences none of us would like to imagine.

      Yes, errors occur when we have to cut corners due to pressure of time, when people are tired, when they are inexperienced for the task, when the diagnosis or treatment are time-critical and/or very complex. But the occurrence rate of those factors will never be zero. The investment in providing close-to-perfect care for an individual would bankrupt the system and close access to all others.

      In my view, error investigation should not just look at whether rational decisions were made, but whether the team did they best they could with the resources and priorities existing at the time. WITHOUT hindsight.

      ANd finally – a message for all those alt.med. providers who gloat about medical error: Try taking on all of health care for all-comers, at any time of day or night, in all age groups, and across all types of medical and surgical conditions, including the most life-threatening and the most urgent. Just for 24 hours. Let’s see your error rate.

      Rant over.

      • Dr Kitty

        Examples:
        An elderly person who has been anti-coagulated to prevent a stroke from atrial fibrillation dies from an intracranial bleed after a minor head injury.

        Someone on metformin and diuretics to manage their diabetes and high blood pressure ends up dehydrated, with an acute renal injury and electrolyte abnormalities after a simple episode of viral gastroenteritis.

        The person on a statin to reduce their risk of heart attack and stroke who ends up with rhabdomyolysis.

        The young woman on a combined pill who has a thrombo-embolic event.

        Nothing was really done “wrong”, but by choosing to minimise some risks, we exposed the patient to others- and in these particular cases those choices did not work out in favour of the patient.

        And those are situations where people may well have been prescribing based on best practice and well known protocols.
        Genuine errors obviously increase the risks substantially.

        • Irène Delse

          Or a person on lithium for their bipolar disorder, who gains weight as a consequence, with other health problems down the line. But the lithium was the right medication for that person’s mental issues.

          I am familiar with such trade-offs on the patient’s side. One of my aunts is on anti-coagulants and she does blood tests regularly as part of harm mitigation: that way the doctors can, hopefully, catch a problem before it gets dangerous. I am myself on several long-term medications, and it’s been clearly explained to me what the possible side-effects were, what things to look for that would mean trouble, and how regular testing of renal function and blood levels of certain compounds were integral to the prevention of harm. It’s boring, at times, but on the plus side, it means that I get to actively participate to my treatment plan.

      • DelphiniumFalcon

        So for medical staff who are already over-worked and expected to remember and note so much it’s more work than it’s worth.

        My additional question is do you think zero-harm mentality would help on the administrative/clinical side since so much of the issue seems to be mistakes on forms or in the EMS? Things like requiring people on the phone to use the NATO phoenetic alphabet when spelling things out like a difficult to spell patient name when asked to spell so it’s uniform and we all know what it means without things like “P like phone” and other stupid phrases sneaking in. Including more health unit coordinators to do things like order tests, input results, and manage the patient tracker so the doctors and nurses can get back to their actual jobs.

        My work right now strictly on the clerical side so that’s why I’m curious if improvements on that side helps the clinical side at all since a lot of the issues I’m seeing here comes down to too much redundant paperwork, not enough patient time.

  • PeggySue

    EARS are absolutely problematic. Having been a software test engineer in a previous period, I am appalled by the poorly designed interfaces, the performance problems, the rapid release cycles with minimal testing that fix a problem or address a requirement while making something else harder. It’s driven by the desire for speed, which seems to make strategic thought and planning a thing of the past.

    • PeggySue

      I meant EHRs

    • Sue

      There is a pervasive myth, put about by the EHR salespeople, that electronic records are the answer to all risks and all ills.

      While electronic data has many advantages for storage and retrieval, it’s the INPUT that is cumbersome, inefficient and error-prone. In fact, electronic medication ordering can cause errors, not just avoid them.

      As a clinician, the interface of all the EHRs I have used (and continue to use) is slow and inflexible. Just to access information and to record my own file notes, I have to log on and off and negotiate multiple screens. The process is repetitive and frustrating.

      The main issue is that, almost universally, these systems are designed primarily for data collection, with clinician documentation being secondary. Back-to-front.

      The fastest way for clinicians to record their notes in rapid-turnover environments is to dictate or write and have secondary transcription – by a scribe or secretary or typing pool.

      Otherwise, rubbish in, rubbish out.

  • attitude devant

    Should we talk about the EHRs now? They terrify me. I’ve been working with them for a good 15 years and was an early proponent, but they have fundamentally changed my interactions with patients. When the patient leaves the exam room I’m supposed to have all orders coded and entered and a visit summary ready to go. What that inevitably means is that I’m doing data entry instead of looking at my patient and listening to her. I HATE that. And yet, that IS the thing that we all, every single one of us, gets evaluated on. How much gets missed because I’m looking for the most specific code for hypothyroidism? Or searching for the proper iteration of a blood test in a list with inconsistent abbreviations?

    • AA

      Owners of medical scribe companies always chime in to say that scribes can solve this problem. It’s rather hilarious since EHRs were supposed to improve efficiency and reduce administrative tasks so scribes would be eliminated (ok ok that’s what they said…not what they intended to do). . I do understand the necessity of having a visit summary ready before the patient is out the door, though. Although you could do it faster if you handwrote it for the patient, but then it wouldn’t be in the chart….

      • chemist mom

        More technology!! Add recordable pens with handwriting recognition — does both at once! (I joke because I have one and love it for transferring answer keys and lecture notes into a digital form that I won’t lose within 10 minutes. Hate paper.)

        If the handwriting isn’t recognizable, I’m sure we can find another technological solution to that!!

      • Lisa Cybergirl

        I heard about medical scribes, and it sounded like a good way to boost my income. Then I found out that it pays around $10 an hour…

        • AA

          AFAIK the medical scribe companies look for students who want a resume-booster for getting into a health professional school.

          • Lisa Cybergirl

            Makes sense, but I’m not sure it’s a good idea

            to make such an important

          • AA

            With this model, I’m unsure of the accuracy of the scribes’ work (even though the provider has to verify and signoff on any of the scribes’ notes)

          • Angie Sol
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    • moto_librarian

      Is there any way that patients can help with this? I have been asked to fill out the Press Ganey a couple of times in the past year, and it asks about time with the provider, but if you don’t contextualize it with comments, I don’t know how helpful that is. I love that all of my providers in the system share access to my records, but I hate that so much time is being spent justifying everything that they do.

      • CandiO

        Well if you really like your provider don’t score them with less than a ten or 5 stars or whatever the maximum is. On a 10 scale the 7 and 8 grades actually HURT your providers scores and screw up their metrics and reimbursement.

      • The Computer Ate My Nym

        Oh, yes, the Press Ganey scores. First, the only study examining the correlation between PG scores and quality of care found an inverse correlation. Second, the scores are, IIRC, 1-5, with 5 being the best. But when the data are collected and analyzed, 1-4 are collapsed into a single category and only 5 is counted as different. So a provider who gets ratings of mostly 3s and 4s will have essentially the same rating as one who gets mostly 1s and 2s. And those with less than 5 have some of their payment withheld because they are “underperforming” providers. In short, the system is designed to punish providers and avoid payment, not to improve quality of care.

      • Angie Sol
    • Azuran

      I have no idea how they work in human hospital. But it feels like they are just over the top complicated with too many codes for stuff and a way too rigorous need for standardization and procedures.
      We use electronic files in my vet clinic and it works like a charm. I’d guess mainly because it doesn’t work with code. I just open a window and write whatever I want whenever I want, however I want to write it.
      If I want to put a visible note on the file that the dog has hypothyroidism I just click on one button and write ‘hypothyroidism’ If I feel like it I can even write which medication at what dosage the dog is taking and magic, this inscription will always be listed at the top of every page of his medical file. I can make quick notes in the files to remember what’s going on then come back later to complete them without any problem.

      • AA

        I think billing may present a big difference. The amount of time and documentation you spend wtih the patient must correspond to the appropriate billing level. For humans, you have to document the complexity of decision making,t eh amount of time in face to face and administrative tasks, and the comprehensiveness of your exam and the health history. A lot of MDs have their notes checked by both documentation specialists and coding specialists, so the note needs to comply.

        • Dr Kitty

          And this is why I like the NHS…
          I can code when it is appropriate, and free text when it isn’t.
          Nobody is looking at my notes except the other GPs in the practice.

          • AA

            I’m still astounded that you, as a GP, are responsible for taking patients’ vital signs in your clinic. It’s just such a different system.

          • Dr Kitty

            But I can multi task while I do it, and only take them if they are relevant.
            I’m not necessarily checking the BP of a 20 year old with an ingrown toenail.

          • AA

            It’s just such a different system in the US. Here, the patient checks in at the main registration desk. At that desk, they pay their copay/coinsurance (if applicable) and confirm your insurance (again, if applicable). There is also a big push to make these registration desks touchscreens rather than talking to a human. If it’s been a while since you have presented to clinic, you also have to electronically sign the privacy notices. Then you check in at the clinic registration desk. At every primary care visit, the medical assistant will take you to the exam room (it’s given a verb…”rooming”), take your height, weight, and blood pressure, and review your medications. The MA will also verify your preferred pharmacy. When I watched the Sherlock BBC episode in which Watson briefly works as a GP, it seemed so incredulous to me. Walking directly into the doctor’s office–wow!

          • The Computer Ate My Nym

            Note that vital signs are nearly always taken in the US because, among other things, you can charge for doing so. At least, vital signs are one of the something like 10 or 12 physical exams “systems” and the more systems you document, the higher the “level of care”. Even if it’s on a 20 year old with an ingrown toenail.

          • Valerie

            That explains why they insisted on taking my blood pressure at a follow-up appointment when my arm was still sore from where the BP machine malfunctioned on it 2 days earlier. The staff were frustrated with me that I demanded somebody do it by hand on my other arm.

          • Angie Sol
          • AA

            Here’s something really crazy–documenting earlobe crease as a system for an exam for a patient with a cardiac problem (google earlobe cardiology)

          • Angie Sol
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          • Dr Kitty

            My patient check in, either with a touch screen, or by letting a receptionist know they have arrived. So they appear on my screen as “arrived”
            When I am ready to see them I literally get up, walk to the waiting room, shout their name, and escort them back to my room.

            There is a payment incentive for making sure all patients over 45 have their BP checked once a year, but it is a hard target to reach, so we just do our best.

          • Angie Sol
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    • MaineJen

      I’ve noticed that. During most visits, the doctor spends more than half the time looking at a screen. :

    • Angie Sol
  • Deborah

    Not to mention that, outcomes aside, patients LIKE a little more time with their doctor. Those 1 hour prenatal appointments are part of the reason that women choose CPM type care.

  • AA

    Indeed, Dr. T. How are MDs supposed to keep up with patient loads when the number of residency spots has not increased for years (thanks, Congress)? How are nurses supposed to keep up with patient cares when their patient load keeps increasing?

  • Megan

    This is an interesting piece in light of another study I read this morning. It noted the rate of physician burnout and that the number of physicians reducing their work hours (working less than full time) may worsen already predicted physician shortages, especially in primary care. I went part time because I wanted to spend some days with my children while they were young but I don’t discount the benefit to my mental health as well. i admit with medicine being the way it is now, I am not looking going back to full time. I am thankful though that I am in academic medicine where I get to spread my time between patient care, teaching and scholarly activity.

    • Dr Kitty

      I work 2.5 days a week, with a proportionate profit share of the business.
      In actuality, I rarely get home before 4 on my “half” day. I usually come in for 2hrs on my days off. I do paperwork on my laptop after dinner. I come in 30 minutes before my first patient arrives, work through lunch and leave 30 minutes after we close the doors.

      It could be worse; my partners who work 4.5 days do paperwork at the weekends and I often come in to see they’ve been issuing prescriptions at 11pm or 5am.

      I laughed the other day when someone complained that GPs should spend 5minutes reading the notes before seeing or speaking with every patient. I see 30-35 patients in a day and do maybe 20 phone calls. That’s an extra 250 minutes a day…which I don’t have.

      • Anne Catherine

        oh my –that is a lot of work–I’m shaking my head.

  • The Computer Ate My Nym

    The fear of making a critical mistake and the feeling that doing so was inevitable with the time and money pressure put on doctors in the current system was the major issue that took me out of clinical medicine. It’s just not worth the anxiety.

    • Monkey Professor for a Head

      This was one of the reasons why I left Ireland for Australia – I was regularly working 34 hour plus shifts with an ever increasing workload. Working conditions are much better in Australia, but even so anxiety over the idea of making a mistake is one of the reasons that I’m happy being a SAHM right now.

  • BeatriceC

    This! I have run up against this problem more times than I can count. One major error that got missed was my youngest son’s hip. He’d been in too much pain to even walk for months. The hip was never mentioned. I finally got desperate and took him to a different hospital where the problem was found. At Shriner’s, they had similar images, but appointments were so rushed they never bothered to look at the hip since he was actually complaining of pain in his whole leg. The surgery to fix the hip was brutal, but he went from completely wheelchair bound to only partially chair bound after recovery.

    Picture to show the deformity that got missed (I cropped out the part with identifying info, which means you can’t see the effect on the pelvic bones, which were shoved in funny positions because of the straightened femoral head).

    • PeggySue

      Merciful heavens. Even I can see that.

    • niteseer

      That is terrible! I am so sorry that happened. I thought that radiologists were supposed to examine the films in detail, and submit a written report. You’d think the doctors would have checked that, even if they didn’t have time to examine the films for themselves.

      • swbarnes2

        Another blog I follow, the author had a similar thing, horrible back pain, and then doctor #5 was like “Oh, I can see the problem plainly on the X-ray here that was taken years ago”. I think the patient’s being overweight likely contributed to the other doctors’ not paying attention.

      • Angie Sol

        The expectation in private practice is 20RVUs per hour. A pelvis radiograph is 0.17 RVUs. Chest radiograph is 0.19. We have to open the study, look for comparisons (and look at them if some are available), look at the history, look at the exam, dictate a report. If there is a critical finding, we need to contact the ordering physician. With radiographs, that means we would need to do 100/hour.

        I am not defending whoever missed this finding, however, “in detail” is relative when you are crunched for time and moving at this ridiculous pace all day long.

        I am terribly sorry this happened, and I hope your baby is ok.

        • BeatriceC

          I’m assuming from your post that you’re a radiologist? Or a radiology tech? Anyway, this is the result of a genetic bone condition called (among other names) Multiple Hereditary Exostoses. Poor kid has a metric shit ton of skeletal issues, this being just one of them. As I replied to Dr. Kitty above, this particular issue was four years ago. The surgery to repair it was absolutely brutal, but after a year of recovery he was walking a good chunk of the time, and after his recovery from the hardware removal two years later, he started doing even better. These days he only uses his chair about 50-60 percent of the time, which is a marked improvement. He’s had other issues in his legs that contribute to using his chair (for pain related reason), but he almost never complains about hip pain anymore.

        • The Computer Ate My Nym

          Lovely. I remember seeing once a shoulder x-ray where the radiologist did a beautiful job of describing the mild arthritis and lack of fracture or other significant abnormality in the bones, but did not comment on the mass in the visible portion of the lung. This image was shown in my medical school class with two morals: 1. Beware of “search satisfaction” (i.e. the tendency to stop looking once you’ve found one thing that is wrong) and 2. look at the x-ray yourself, even when you completely trust the radiologist because anyone can miss something, especially if you wrote on the clinical information “shoulder pain” and didn’t mention the patient’s smoking history or cough (or whatever else). At the time, the rate at which radiologists were expected to work was not mentioned as a major issue, but I can easily see how something, even something like a large mass, could be missed in the time pressure.

    • Dr Kitty

      How in holy hell was that missed?
      Are you doing ok?

      It is the responsibility of the person who orders a test to act on the result and communicate the result and the plan to the patient.

      Unfortunately, I still have patients who have scans or tests ordered by specialists, and are told “oh, your GP can look up the result and tell you”.

      Which makes it very difficult if the scan shows something terrible, I have no idea what the specialist was planning to do about it, and there is a patient sitting in front of me waiting to hear the result.

      • Azuran

        I hate when they do that. We’ve send a few cases to an ophtalmologist and the reports always said: Follow up in a week with your regular veterinarian. But she does not give me any kind of info on what am I supposed to do, what should I look for? should I be doing any kind of specific testing? or even how long the patient is supposed to continue the medication. If I knew how to handle the case, I wouldn’t have referred it to a specialist in the first place…

      • BeatriceC

        My apologizes for brain-fog induced lack of clarity. This was four years ago. He had it repaired and he’s doing much better, especially since the hardware came out two years ago.

        And as for how it got missed? I blame lack of time. He was complaining about pain pretty much everywhere besides his hip, so they never looked at it. They were so rushed in appointments that they took less than a minute to scan the images of the areas where he was complaining about pain. This is a cropped version of the picture. In the actual shot, it’s a full leg image. They were looking at his knees, tibia and fibula, and ankles, which is where he was complaining about pain. Since they kept asking about “pain” the 10 year old child didn’t mention the numbness and “funny feelings” in his hips. The surgeon who actually notated the issue and fixed it hypothesized that the pain he was feeling was a domino effect kind of thing. The deformed femoral head was causing his gait to change, which caused a chain reaction of pain, which was more uncomfortable to the child than the numb and tingly hip itself. They did an osteotomy, using his own bone to do the repair, in hopes that will hold for the rest of his life and he won’t need a hip replacement. He was initially worried he’d have to to the same thing with the pelvic bones, but it turned out that they weren’t actually deformed, just sitting in weird places because of the femoral head being straight.

      • Margo

        I can empathise with you. We often refer women to clinic, three hours away from where we live. Women are seen in antenatal clinic and are often sent home with no paperwork or results pending, not ideal when the women turn up at our local midwifery clinic, wanting results and guidance from us, when we actually do not have the information available. This then leads to hurried follow up phone calls to the hospital and a quick chat with the consultant whilst the woman sits in front of us wondering what the hell is going on. Paperwork and lack of communication makes what should be fairly simple somewhat complicated.