How many U.S. deaths result from medical error?
May 6, 2016 11:03 AM   Subscribe

"A study by researchers at Johns Hopkins Medicine says medical errors should rank as the third-leading cause of death in the United States." - ProPublica

The study, published in The BMJ, and the open letter to the CDC

ProPublica's series on patient safety from reporters Marshall Allen and Olga Pierce: "Our goal is to find out why so many patients are suffering harm and highlight the best ways to solve the problem."

ProPublica's Patient Safety FB group (3,600+ members), Patient Harm Questionnaire, and questionnaire for health care providers

The landmark 1999 study from the Institute of Medicine, "To Err is Human: Building a Safer Health System"

Resources from the National Patient Safety Foundation, including a checklist for getting the right diagnosis, tips on preventing infections in the hospital, a guide to safety at the pharmacy, patient-safety facts and statistics, and more

"Doctors Confess Their Fatal Mistakes" in Reader's Digest, in which doctors and a nurse share the stories of their medical mistakes and explain how such errors could be prevented (apologies: slideshow)

Dr. Brian Goldman's TEDx Toronto talk from 2010, "Brian Goldman: Doctors make mistakes. Can we talk about that?"

Previously; previously; previously; previously
posted by trillian (47 comments total) 34 users marked this as a favorite
 
I wonder how the mistakes are distributed? Are there some really careless doctors killing tons of people?
posted by Iax at 11:15 AM on May 6, 2016 [1 favorite]


Are there some really careless doctors killing tons of people?

Old Joke:

What do you call the worst graduating student in med school?

Doctor.
posted by IndigoJones at 11:18 AM on May 6, 2016 [13 favorites]


I wonder how the mistakes are distributed? Are there some really careless doctors killing tons of people?

Yes. It's actually been shown that malpractice is an issue of known bad actors being allowed to continue practicing weighting the scale.

This is one of the biggest reasons I have no sympathy for doctors complaining about malpractice premiums.
posted by NoxAeternum at 11:20 AM on May 6, 2016 [10 favorites]


I saw this headline yesterday and I'm having trouble considering the diffuse actions of a group of people to be a statistical "cause of death."
posted by rhizome at 11:22 AM on May 6, 2016


And as horrible as it seems, mistakes happen. People die. The important part of this sort of coding (categorizing) is so we can figure out why and learn, so that maybe it won't happen that way again. But hospitals and doctors are risk adverse, so there's a reluctance to examine this (or even admit it happens). No one wants to be told the reason mom died was because the doctor fucked up, but it should be an acceptable answer. Sometimes you break things trying to fix them, including people. Pretending this is somehow not the case does a disservice to everyone.
posted by cjorgensen at 11:24 AM on May 6, 2016 [19 favorites]


Yes. It's actually been shown that malpractice is an issue of known bad actors being allowed to continue practicing weighting the scale.

This is one of the biggest reasons I have no sympathy for doctors complaining about malpractice premiums.


You believe that malpractice is primarily an act committed by a small group of bad actors and therefore have no sympathy for the majority of well intentioned actors who suffer disproportionately for the actions of the few? Seems backward?
posted by telegraph at 11:28 AM on May 6, 2016 [15 favorites]


I saw this headline yesterday and I'm having trouble considering the diffuse actions of a group of people to be a statistical "cause of death."

Couldn't you describe pretty much every other statistical "cause of death" as the diffuse actions of a group of people, though? It's not like there's one guy out there ramming 30,000 people on the highway every year.
posted by Etrigan at 11:32 AM on May 6, 2016 [17 favorites]


You believe that malpractice is primarily an act committed by a small group of bad actors and therefore have no sympathy for the majority of well intentioned actors who suffer disproportionately for the actions of the few? Seems backward?

No, not if the majority of well-intentioned actors refuse to hold the bad actors accountable. They pay high premiums if they won't acknowledge that this happens and take action to address the issue.
posted by suelac at 11:32 AM on May 6, 2016 [8 favorites]


I teach my students about medication errors (those medical errors that come from pharmaceuticals) and provide these statistics: In one recent study 38,000 definite errors and 3,300 possible errors were found in one year at 184 hospitals. Of these, 1,233 injured the patients. Another study found one in four hospitalized patients experience a medication error.

Death by medical error is cited in the above articles, but the sheer number of errors, most of them not causing injury, is staggering.
posted by dances_with_sneetches at 11:33 AM on May 6, 2016 [1 favorite]


You believe that malpractice is primarily an act committed by a small group of bad actors and therefore have no sympathy for the majority of well intentioned actors who suffer disproportionately for the actions of the few?

Yes, because the well intentioned majority refuses to deal with their bad actors. The whole issue could be fixed by being more aggressive about getting bad doctors out of practice, but the community refuses to do so, because it would require empowering the state to more rigorously regulate their profession.
posted by NoxAeternum at 11:34 AM on May 6, 2016 [9 favorites]


Another study found one in four hospitalized patients experience a medication error.

Oh, this one's incredibly infuriating, because it's actually a fixed problem for the most part, thanks to the VA!
posted by NoxAeternum at 11:35 AM on May 6, 2016


Yes, because the well intentioned majority refuses to deal with their bad actors. The whole issue could be fixed by being more aggressive about getting bad doctors out of practice, but the community refuses to do so, because it would require empowering the state to more rigorously regulate their profession.

But doctors by and large are neither regulators nor legislators. Doctors practice within a legislative environment that they often have no control over (c.f. abortion regulations). Physicians are not a self-policing community like, for example, the Catholic priesthood.

I know this feels like a derail but if we're going to be talking about regulation of malpractice and physician mistakes, I think we need to be clear from the beginning that the vast majority of physicians have control only over their own practice (and sometimes their scope of control is smaller, if they practice in a state where their ability to practice evidence based medicine is limited, or if their employment contract requires that they not provide medically sound procedures and care).
posted by telegraph at 11:43 AM on May 6, 2016 [8 favorites]


This is one of the biggest reasons I have no sympathy for doctors complaining about malpractice premiums.

The problem is those premiums just get passed onto the consumers. It's the same reason we can't fix misbehavior by bad banks by fining them - the stockholders may take a little hit but until the individuals that are at fault are held directly responsible, the bad actors are just going to keep going.
posted by Candleman at 11:50 AM on May 6, 2016 [1 favorite]


There are plenty of reasons to partition cause-of-death by underlying condition. Medical errors don't just randomly affect the population--they're generally associated with an attempt to treat a condition. So for some purposes, it does make sense to focus on the more distal cause -- e.g. the heart disease that caused a patient to go in for (botched) surgery. Medical error is part of the risk of any serious condition and should be counted as part of that risk.

But that's only one way to divide up the causes, and the one you want depends on what question you want to answer. There are lots of other natural groupings, among them medical error. (Do we lump all homicides and all accidents together, or group by instrument like car or gun? If a chemo patient dies of pneumonia is that cancer or pneumonia or side effects of medication?)

It seems that the underlying "problem" here is with the CDC's decisions about how to present summary data (and in particular to insist on one official set of numbers)--not with the reporting that's already available on death certificates. Maybe (hopefully) our capacity to analyze and understand data goes beyond making bar charts of mutually-exclusive causes of death. We could do more sophisticated analysis in addition, as the researchers did, and the CDC could release the results officially. Fighting instead about which partition is "correct" seems a bit of a waste of time.
posted by cogitron at 11:53 AM on May 6, 2016 [2 favorites]


Jonathan Brewster: Then three in Chicago and one in South Bend. That makes thirteen.

Dr. Einstein: You cannot count the one in South Bend. He died of pneumonia!

Jonathan Brewster: He wouldn't have died of pneumonia if I hadn't shot him!

Dr. Einstein: No, no, Johnny. You cannot count him.

(Arsenic and Old Lace)
posted by dances_with_sneetches at 11:57 AM on May 6, 2016 [2 favorites]


But doctors by and large are neither regulators nor legislators. Doctors practice within a legislative environment that they often have no control over (c.f. abortion regulations). Physicians are not a self-policing community like, for example, the Catholic priesthood.

You see that big elephant over in the middle of the room? The one with the big "AMA" tattoo on it?

Sorry, but you don't get to ignore him. Doctors as a profession are incredibly politically powerful in the US, thanks to their guild.
posted by NoxAeternum at 12:13 PM on May 6, 2016 [15 favorites]


It's not like there's one guy out there ramming 30,000 people on the highway every year.

Vehicular Manslaughter Georg
posted by figurant at 12:31 PM on May 6, 2016 [14 favorites]


I remember being told years ago that medical staff work 12 hour shifts and thinking "that's stupid, when you get that tired you screw up and if they screw up people die." I was hastily reassured by people in the profession that no it was fine, doctors had to work that way for Important Reasons, despite all the evidence we have that fatigue leads to errors in judgement and again, when they screw up, people die.

It ended in me just not bringing it up anymore. Too many people in the medical field are convinced that unlike all other humans, they can make good judgments after 12 hours or 24 hours of no to little sleep doing grueling, stressful, incredibly complex work.

I would like to see just that one attitude change, honestly.

I don't know if that particular issue is buried somewhere in these reports, but I'd be surprised if it wasn't.
posted by emjaybee at 12:46 PM on May 6, 2016 [77 favorites]


You see that big elephant over in the middle of the room? The one with the big "AMA" tattoo on it? Sorry, but you don't get to ignore him. Doctors as a profession are incredibly politically powerful in the US, thanks to their guild.

The vast majority of US doctors are not AMA members. Only 15% of practicing doctors are members (you'll get a higher if you count medical students, residents, and retirees, but none of those people are in a position to make changes), a drastic decline from the early-1950s high of 75%. It used to be their guild. It isn't today.
posted by cjelli at 12:52 PM on May 6, 2016 [5 favorites]


Couldn't you describe pretty much every other statistical "cause of death" as the diffuse actions of a group of people, though? It's not like there's one guy out there ramming 30,000 people on the highway every year.

Sure, but there is no unified push to do something about car accidents as a whole, only for specific causes. The logic of the medical errors camp smooshes the specifics together into a nebulous "patients are suffering harm." To draw the connection you'd have to say, "what are we doing to do about so many cars crashing?" You look at the details, which are more or less known, just like in medical procedures. If prescription errors are a big cause of harm, a similar strategy to e.g. ignition interlocks for drunk drivers would be, to use a classic trope, improving doctor handwriting.

That said, there is a Law Enforcement-like aversion to oversight and many doctors consider themselves godlike. I'm sure malpractice insurance is a shitshow of expensive premiums, regulatory capture, and recission practices for those who have to participate in it, but I'm still not convinced that "third leading cause of death" is a great path on which to confront the morass that has gotten us to this point.

When my dad was in the hospital the last time, he had only been sent home from his previous visit a few days before, but wound up trying to walk around and happened to fall on his face on the tile hallway. His first night back in the hospital he did the "I'm feeling pretty independent!" thing and tried to get out of his bed. He again fell on his face, this time having to be rescuscitated (against DNR, which was not properly submitted. Have a hard copy, people!). I was dating an RN at the time, and she said that given his age, condition, and talent for faceplants it would be standard procedure for him to have been on a bed alarm that would signal when he tried to get out of bed. We brought this up to the staff who were bringing us up to speed, and there was a bit of a dance around what constitutes a cause to use a bed alarm. I speculated at the time that this was the point at which we could make it a malpractice issue, but it was also understandable (even discounting defensive sophistry on the hospital's part) that there are myriad judgement calls involved in healthcare. Sometimes they're wrong or inadequate, and I'm not going to go to the mat yelling "but the leeches didn't work!"

I'm not going as far as "you pays your money, you takes your chances." I'm just trying to be realistic about the concept of malpractice and the imprecise and constantly evolving nature of medicine as a human endeavor. I think we're in the throes of the Information Age after a solid couple of centuries of medical innovation, and I think there's an undercurrent of faith in science that sits in tension with the standard "God has taken our lovely person home." I think the advances in medicine and technology (with their concomitant hype) has given people an unreasonable expectation that data and technology makes all perfect treatments visible.

Bad doctors and the like are one thing, and they should be detected with similar Sabermetric analysis like people are starting to use to find bad cops, but at the end of the day, medicine is not perfect and we shouldn't pretend that a greater technological ability to do root-cause analysis after the fact changes that. Chalking up the third greatest cause of death to "doctor stuff," seems like a category error to me.
posted by rhizome at 12:59 PM on May 6, 2016 [2 favorites]


Yeah the idea that this is just the big bad cabal of doctors who love money and dead patients is laughable. Nurses make many med errors--they are the ones doing much more of the hands on and day to day stuff. The big bad money grubbing doctors aren't making them doing and certainly aren't protecting nurses. Also many hospitals have protocols for whenever a med error is made regardless of if it hurt anyone.
posted by MisantropicPainforest at 1:01 PM on May 6, 2016 [2 favorites]


The vast majority of US doctors are not AMA members.

Less than 5 percent of U.S. gun owners are NRA members, but they still have an outsized influence on legislation.
posted by Etrigan at 1:03 PM on May 6, 2016 [2 favorites]


Less than 5 percent of U.S. gun owners are NRA members, but they still have an outsized influence on legislation.

'They' being the NRA, not 'gun owners.' In the same fashion, the AMA certainly exercises an outsized (and generally bad -- there's a reason why their membership keeps dropping) influence on legislation, but 'doctors' do not.
posted by cjelli at 1:06 PM on May 6, 2016 [2 favorites]


In the same fashion, the AMA certainly exercises an outsized (and generally bad -- there's a reason why their membership keeps dropping) influence on legislation, but 'doctors' do not.

In the absence of a similar organization that spends eight figures annually on "advocating on behalf of physicians and patients", "doctors" have outsized influence on legislation.
posted by Etrigan at 1:14 PM on May 6, 2016 [1 favorite]


Those are pretty crap methods. They're a little obtuse about how they're doing their math, but their paper (http://www.bmj.com/content/bmj/353/bmj.i2139.full.pdf) is a literature review of four other studies, three of which include <2400 patients and the fourth (by Healthgrades.com) includes 37,000,000. (paper at: Link. NB: can't find the 2004 version so this is an updated 2011 version)

In order to come up with their 251,454 "composite" number, it looks like they weighted each study according to how many people were in it. Which is to say that since there were four orders of magnitude more patients in the Healthgrades study, the "weighted" average this author came up with (251,454) is exactly the same as the Healthgrades result (251,454).

Which is all to say that this guy got published in a major medical journal by essentially parroting back the results of a study conducted between 2000-2002 and published in 2004, a study which only covers patients in hospitals and itself freely admits:

"The models can only account for risk factors that are coded into the billing data. Therefore, if a particular risk factor was not coded into the billing data (such as a patient's socioeconomic status and health behavior), then it was not accounted for with these models."

One might argue that if poverty were taken into account, the push would not be to improve quality of hospital care but rather to fight poverty and prevent the hospitalizations in the first place.

People die in hospitals-- more often than they should and I do believe that medical mistakes contribute to a large number of those deaths. Makary's article sets forth a useful framework to address errors, but his research is both deeply flawed and short-sighted. Quality improvement should be an important aspect of any organization that claims to help people, but to suggest that hospital QI alone could avert a quarter million deaths a year is preposterous.
posted by The White Hat at 1:16 PM on May 6, 2016 [7 favorites]


In the absence of a similar organization that spends eight figures annually on "advocating on behalf of physicians and patients"

That's because there are a large number of smaller organizations that each spend seven figures rather than having one single eight-figure alternative to the AMA.
posted by cjelli at 1:23 PM on May 6, 2016


Those are pretty crap methods.

Am I wrong that this isn't a research paper but an open letter reporting that many of the studies done on medical error suggests that the number is very high?
posted by MisantropicPainforest at 1:24 PM on May 6, 2016


Am I the only one who sees a correlation between this and the number of hours some medical practitioners work? I remember my GP saying that, during his residency, he felt like he nearly had the early stages of dementia. 48 hour shifts are not conducive to sound decisions. I remember it being mentioned in another thread that sometimes these hours are unnecessary, and are almost a form of hazing, where older doctors think, "I had to go through it, so should they."

Really, medical schooling should be subsidized. More doctors, lower cost of care, better hours.
posted by constantinescharity at 1:24 PM on May 6, 2016 [10 favorites]


That's because there are a large number of smaller organizations that each spend seven figures rather than having one single eight-figure alternative to the AMA.

Go ahead and check that list against Member Organizations of the AMA. I doubt they're pushing too hard to position themselves as alternatives.
posted by Etrigan at 1:32 PM on May 6, 2016


The framing of this ("third-leading cause of death in the United States") strikes me. *Shouldn't* it be the case that most deaths are errors? If we're talking absolute numbers, then sure; things should be done to reduce that number.
posted by l_zzie at 1:43 PM on May 6, 2016


This is one of the biggest reasons I have no sympathy for doctors complaining about malpractice premiums.

Well, malpractice premiums are also high because it's cheaper for hospitals to settle lawsuits (whether or not they have merit) than litigate. So doctors take the hit, and their premiums go up.
posted by Existential Dread at 1:48 PM on May 6, 2016


Go ahead and check that list against Member Organizations of the AMA. I doubt they're pushing too hard to position themselves as alternatives.

That's a fair point, and I admit I was not aware of the degree of overlap, which is small by number of organizations, but large by dollars of lobbying.
posted by cjelli at 1:58 PM on May 6, 2016


Yeah the idea that this is just the big bad cabal of doctors who love money and dead patients is laughable.

It's likely a bunch of factors - lack of sleep; something about the hierarchical structure + liability issues + culture that make it difficult for doctors to admit errors, and for people up and down the chain to call them on it when necessary; hospitals wanting to protect themselves as institutions because of liability (or quality ratings where applicable, etc).

Personally, my main issue with doctors per se is that very few of them seem to be willing to admit that they're just as prone to error as any other person. Or that any system or technology they're involved in or use is prone to error or variance. I'm sure there are disincentives for testing things more than once or using more tests than are justified by stats. But I also suspect they just don't like the idea of being wrong, or having anything to do with things going wrong. A lot of them aren't really up for engaging patients as collaborators in their own health care. Whether that's to do with systemic issues (available time) or some kind of selection bias re personality factors, or both, idk. (Well, those are my guesses.)
posted by cotton dress sock at 2:09 PM on May 6, 2016 [1 favorite]


The vast majority of US doctors are not AMA members.

That's not where the real authority juice is though. It's the state medical boards which are always stacked with doctors (maybe they should be but I haven't really thought that hard about it since I have only recently become a subject of the US medical system).
posted by srboisvert at 2:28 PM on May 6, 2016 [1 favorite]


Errors in medicine, like errors in any other complex area, are rarely just about one person being lazy, incompetent, etc. Looking just for "bad apples" will not fix much. We need to look at what systemic factors led to the conditions that made it likely for the error to happen.

What role does time pressures play? What about overworked staff? What about equipment and software that is poorly designed? What about contradictory protocols?

I know many physicians can be defensive about the possibility of mistakes (and this is something that good medical school programs are working to change). Looking at the whole system, and not just focusing on "how can we blame the doctor" will help. This is one big reason why aviation has a good safety record. Instead of just blaming the pilot, investigators look at the design of the cockpit and controls, the role of practices regarding training and sleep, the communication between crew members and air traffic control, and other things.
posted by neutralmojo at 2:46 PM on May 6, 2016 [4 favorites]


A few things that I think would help-

1) Sleep. Why do we tolerate the systemic sleep deprivation of a group of people who are supposed to be experts in health? If residency programs insisted that doctors smoke cigarettes, we would think it was insane. Sleep deprivation can be just as harmful to health as smoking. Even worse, it seriously screws with your cognition. Current guidelines are for residents to "only" work 80 hours a week, but many residents claim that these guidelines have just forced them underreport their hours. We need a way to hold hospitals accountable for this. I'd also like to see the limit dropped to 60 hours.

2) Strict nursing ratios. No more that 5 patients for the floor. No more that 2 patients in intensive care. Nurses are your final line of defense for many medical mistakes. If they are understaffed and overworked (not to mention underpaid) then they, like any human, will not be as diligent.

3) Encourage a culture were anyone can speak up and question an order. Residents, nurses, APRNs, PAs, RTs and techs should all feel that they should be able to question an attending without getting reamed out. In my experience this is getting better, but in many places the strict hierarchy is alive an well.
posted by brevator at 3:30 PM on May 6, 2016 [9 favorites]


Why is 80 hours a week acceptable? Shit, why is 60 hours a week acceptable? This is something I've always wondered about too, why it's somehow acceptable for residents to work those ridiculous hours. I certainly wouldn't trust any code written by a programmer who had been up for 24 hours, it's absurd that we want physicians doing that.
posted by phliar at 4:32 PM on May 6, 2016 [10 favorites]


cotton dress sock: "Personally, my main issue with doctors per se is that very few of them seem to be willing to admit that they're just as prone to error as any other person."

While it's not a great excuse for this type of thinking, very few people other than doctors are in the position of both frequently having patients die and frequently making decisions that will hasten or postpone that death. I imagine many doctors end up with the combined mental traits of infallibility and fatalism as a way of protecting them from the mental trauma of being responsible for somebody's death.
posted by WaylandSmith at 4:33 PM on May 6, 2016 [2 favorites]


Mistakes occur. Doctors are human. They can be tired, distracted, angry, myopic, and hurried. Their have gaps in their knowledge base, not keep up to date, and, in addition to Rumsfeld's lemmas, definitely be absolutely sure of things which are frankly wrong (because medical knowledge is a hodge-podge of facts, tradition, and opinion, not hardly scientific for a large part, if you look critically). Some mistakes cause cause harm, some don't, thankfully. But, they will always be with us.

In Florida, mandatory CME on "Prevention of Medical Errors" is required every two years. These courses, interestingly, are usually taught but persons who work for malpractice insurance companies. The content is drawn from malpractice cases and emphasizes documentation. There is discussion of system analysis and identifying high risk situations, but those programs are given as examples. Success of this approach is mostly apparent in the push to reduce medication errors. There have been great strides in reduction of medication errors (electronic hospital ordering systems are nearly universal, interactions are electronically flagged at the time of order entry, packaging and drug names have been changed, meds are dispensed in unit doses electronically, and so on).

I see the electronic medical record and quality measures as another source of risk. The EHRs are promoting sloppy behavior. Out-patient doctors often hand off the patient to a hospitalist, who does not know the patient as well. Instead of doctors taking a history, prior history in the EHR is cut and pasted. The days of going to the medical records room and pulling up the charts of the past 10-15 years are gone; the history on the EHR is "complete" only 2-3 years back. The past history is often initially entered by a secretary in Admission or a rushed nurse in the ER. It's GIGO propagating through the system. The EHR is audited by nurses in the QI Dept. and by algorithms. Electronic reminders pop up instructing doctors in proper documentation about additional diagnoses and comorbid conditions to maximize billing. Clinical pathways are identified and rigidly applied to both the 50 and the 90 year old in what counts for "quality" (which is increasingly tied to reimbursement). Quality metrics are perverse or ridiculous. For example, one of the metrics for colonoscopy is withdrawal time, ignoring the fact that inspection, biopsies, and polypectomy are done both during insertion and withdrawal.

At this point, most errors I have seen in practice are diagnostic errors. Doctors fail to question their conclusions and fail to keep asking "Why?" The orders may be appropriate for the stated diagnosis but the diagnosis is wrong or incomplete. Most injuries I have seen are procedural, not always due to mistakes or deficiencies in skill (those are present) but due to limitations in the technology. There is a certain baseline occurrence of perforations with colonoscopic polypectomy or endoscopic sphincterotomy, even in the best hands. Sometimes, traction on the gallblabber to better expose Calot's triangle will avulse the cystic artery. Wound and hospital acquired infections are a growing problem related to older patients, immunosuppressives, and increasing antibiotic resistance, but also due to inadequate emphasis on hand washing.

The hospitals are getting safer but a hospital is a dangerous place. I would advise all mefites to avoid them like the plague. If you're in one, insist personnel wash their hands when they enter your room and get out as soon as possible.
posted by sudogeek at 4:39 PM on May 6, 2016 [10 favorites]


Seriously get out of the hospital as soon as possible and only have what you need done.

Actually in Social work I've encountered some interesting talk on how people who over access medical care (for like anxiety) are more likely to end up with an hospital aquired infection, or a procedure that goes badly, because the more things that happen inside the walls of a hospital the more likely something bad is to happen.

I'm not medical personnel, but I work in a hospital. Today on my double I forgot where a particular ICU was. (In my defense, I haven't worked here very long) I asked another staff member who then directed me to the wrong place. I have no idea how medical staff handle sleep dep.
posted by AlexiaSky at 7:22 PM on May 6, 2016 [5 favorites]


There's so much I could address in this thread, but I'll stay on point and say that sudogeek really hit a nail on its head regarding EHRs.

I've written about how terrible one particular EHR is. It really is built on top of billing software, and it shows with its terrible user interface and methods of communicating information. I spent a LOT of time developing macros and templates for my group in order to maximize consistency, ease of use, and usability while trying to avoid cascading errors.

(And here I've spent 30 minutes typing, deleting, and trying again to get out what I mean.)

Ok, let's try this again: I'll try to show you what I mean by going through the process of writing a daily progress note for a patient visit in a hospital setting, using one method suggested by the EHR folks and a built-in-template. Let us suppose that we're visiting a 45-year-old male patient with a past medical history of hypertension, who is in the hospital now for an infected left middle finger. We have just completed our patient visit, and now we sit ourselves before the computer and write our note.

THE BAD WAY OF DOING THINGS
I click open the patient's chart. I click on the "hey, let's use a built-in template" button, and use a built-in template. It pulls in all sorts of information from other parts of the patient's medical record, and plugs them all in for convenience. All we have to do now, in theory, is to click and type a few things to complete the note.

I type in my subjective impression of the visit:
Patient has no complaints and feels well. His finger is much less swollen, and the redness is gone. He is able to bend it now, and is able to hold things like a cheeseburger, which he had enjoyed for lunch.

I navigate to the Review of Systems check boxes to tick off pertinent negatives:
Patient denies: ✓Fevers, ✓Chills, ✓Nausea, ✓Vomiting, ✓Chest Pain, ✓Shortness of Breath, ✓Abdominal Pain, ✓Edema, ✓Rash.

The template automatically pulls in a list of the patient's medications and the most recent set of vital signs, and I move on to complete the Physical Exam section, which is a combination of fields, check boxes, and drop-down menu items:
Medications: 1. Aspirin EC 81 mg PO daily 2. Bactrim DS 800 mg/160 mg PO twice daily 3. Lisinopril 5 mg PO daily 4. Metoprolol tartrate 25 mg PO twice daily.

Vitals: Temp 99.2 HR 77 BP 117/72 RR 16 SpO2 99%
Physical Exam:
General: WD/WN, Awake, Alert, Ox[3]. NAD.
Cardiac: RRR, no m/r/g.
Pulmonary: CTA [B]
Abdomen: Soft, NT, ND, NABS. No masses.
Extremities: No CT, no edema. [L] _3rd_ [Finger] _without calor, erythema, edema_.


The template automatically pulls on all of the labwork from the past 24hrs, and we complete our note by typing in our plan, addressing each problem in the Problem List, which is also pulled in automatically (here I'll skip writing out a bunch of labs. I will grant you this one mercy):
Problem List:
1. Allergic rhinitis

2. Cellulitis of finger, left
Much improved. Continue antibiotics.
3. Hypertension
No acute issues. Blood pressure within normal limits. Continue outpatient medications: lisinopril, metoprolol.
4. Sepsis
Due to above. Resolved.


And that's that! I click the button to electronically sign, date, and time the note. Cool beans, right? Yeah, it does look like shit, but that's how the suggested sample template runs, basically. Lists that aren't lists, but run-on sentences. A hodgepodge of checkmarks and filled-in fields. Problems that are sorted alphabetically, and not by order of severity. And the dreaded "note bloat," where what should be a concise note turns into pages and pages of crap automatically imported in from other places in the patient's record: I'm looking at you, Labs section! To the EHR company's credit, they do tell you about "note bloat" and offer suggestions on why and how to avoid it. Unfortunately, it's still there in their supplied templates.

So what's so bad about this, apart from the way it looks? Well, I mentioned the problem list that's sorted alphabetically and not by severity. That's pretty significant, especially in patients who have many medical problems. Or who have poorly maintained problem lists, where resolved problems aren't removed and persist, resulting in a problem list a mile long.

Check boxes and drop-down selections are a terrible way to select things in some circumstances. Either you miss and mis-click on the wrong item or selection, or what you're looking for isn't there to select. Or the template has all check boxes ticked off and you have to uncheck items.

Importing data is only as good if you have good data representing itself neatly: this particular EHR is terrible at doing this. For example: one way of communicating a patient's blood counts (WBC, hemoglobin, hematocrit, platelet count) is to write out a big "X." The left space is used to write the WBC. The top and bottom spaces for the H/H. The right space for the platelet count.

Instead, the EHR imports and lists the labs like this:

- WBC 8.8
- Hemoglobin 14.7
- Hematocrit 34.4
- Platelet count 156


This ain't so bad, but imagine doing this for 20+ lines that comprise "basic" daily labwork. It's very, very difficult to read.

But here's the part that kills me: when you write a note, you have the option of importing a previous note. That's right: you can use yesterday's note today, and the template will automatically pull in everything it's built to pull in, updating the current medication list, the most recent set of vital signs, the labs, the problem list, etc.

What isn't updated as such-- the stuff that you've documented manually-- is copied over. Now all you have to do is update it!

EXCEPT THAT PEOPLE DON'T ALWAYS UPDATE THE NOTE
I've seen charts where the patient is "...able to bend it now, and is able to hold things like a cheeseburger, which he had enjoyed for lunch" EVERY. SINGLE. FUCKING. DAY. Where the plan of care is not updated, and the patient's cellulitis is "Much improved," day after day, without resolution.

And if that's not enough, I've seen notes that are out-and-out LIES. Templates that have a complete and comprehensive Review of Systems and Physical Exam section already filled out, where the notewriter doesn't delete things that they didn't ask or examine. Somehow, in the span of 10 minutes, the physician asks all possible questions and examines every part of the body, even in patients who are comatose or otherwise cannot reply, or who have a limb amputated.

THIS IS WHAT WE'RE PUSHED TOWARD
In the name of, what, efficiency? No, documentation and productivity. For billing and coding. To collect money, to make money. To generate good numbers for Metrics and Reasons, for bonuses for oneself, bonuses for the CEO, bonuses for the hospital. See more patients. Ask every question, examine every body part, personally read and interpret every imaging study and EKG for maximum billing. Every day.

THE METHODS USED TO PREVENT ERRORS ENCOURAGE THEM INSTEAD
This is true, too, of errors relating to drug dosages and schedules, interactions, and contraindications. Or measures to ensure that we have a reason to prescribe certain drugs, or to ensure we asked specific questions such as code status, or whether or not we mean to keep a urinary catheter in place, or if we've ensured that heart failure patients are on certain specific classes of drugs.

Take simvastatin. Simvastatin (Zocor) has a bunch of interactions with other drugs metabolized by the liver. When you order it or another drug in addition to it, you will often see a screen that pops up for interactions. Great, right? Except that it happens so often that physicians will often override the warning by selecting: Reason to continue (drop-down menu item: REVIEWED).

"Wow, what an amazing way of getting rid of an annoying screen!" Myeah, right? But oh, this happens for so many other scenarios. "Hard stops," or prompts that will not allow a user to proceed making changes to the record or medication orders, are designed to make the user think about things. Take proton pump inhibitors, like omeprazole (Prilosec). This class of medications is not just overprescribed, but also fraught with risk (I'll leave you to look up the dangers of long-term use of PPIs). Our hospital system will not let you order PPIs without a hard stop where you MUST select a reason for their use.

This is supposed to be a good thing. Except physicians see this happen so often, and get so irritated by it, that they'll sometimes just click on any reason to see the screen go away. After all, the patient was taking it outside the hospital, so why not just continue it? There must be a reason why, but hell if I've got time to figure it out, or counsel and educate the patient about discontinuing it or allowing them to make an informed decision.

There's a screen and alert that pops up whenever you enter dosage or scheduling parameters that are out of bounds. Take for example, lorazepam (Ativan). If you enter the order to give the patient 50 mg of Ativan by mouth daily, the system will hit the brakes and ask, "HEY. WOAH THERE. THAT'S A LOT OF ATIVAN. DO YOU REALLY MEAN THAT?" And you can select "yes!" Or how about 1 mg of Ativan by mouth, fifty times a day? Well, you can override that, too.

Of course, I would imagine that most people would recognize numbers that just look wrong. As humans, we're pretty good at picking out things that are novel or unfamiliar. Things that are out of bounds. But there's danger, and one must ask: who determines these boundaries? Well, that's a great fucking question right there. The people who determine such things are the same people who say it's ok to write a set of orders for alcohol withdrawal, where there are more than SIX orders for Ativan, ALL of which are flagged as being way too much, because they're all triggered to run at different scores of an alcohol withdrawal pathway assessment score, and all are administered, technically, to be so frequent as to result in ridiculous amounts of Ativan that could be given in a 24-hour period. And what do we do? Well, we read the orders carefully, see that they're very specific and state that the drug is to be given ONLY at specific thresholds and scores, and not all at once, or all the time. And then we fucking click "yes." Do we check to see if the orders are exactly the same as when we carefully reviewed them the first time? Has the time of last update changed at all? Are we sure we're not going to kill someone?

Some people will basically do whatever it takes to make such annoying things go away. It's terrible, and lazy, and horrifying, I know. But that's not the half of it: there are other ways to be terrible and lazy!

MORE STUPID ERRORS THAT ARGUABLY SMART PEOPLE MAKE
Some people can't type or won't type. So they dictate into a microphone and never review it ("Dictated by not read." How many times have you seen that?). Or they will cut-and-paste parts of other people's notes into their own, because they can't be bothered to do the same exam or ask the same questions or take the time to type things out.

I've seen consultant notes copy-and-paste whole blocks of text. I remember one cardiologist at another facility crib the entirety of the history I took from a patient AND much of my plan of care not once, but TWICE. In the same note. That's right: somehow in the frenzy of pasting his note together, he lost track of things and pasted most things TWICE.

As I'd mentioned earlier, I've seen notes where the plan of care or physical exam hasn't changed in days. I'd actually gotten into a heated argument with another physician about this. He argued that if the physical exam or problems and plan of care hadn't changed, what's wrong with copying such sections verbatim? If there is no change, there is no change. And he's right. There's no inaccuracy in copying-and-pasting things if what you're copying is true, and truly unchanged.

Except that "you're not wrong, Walter. You're JUST an ASSHOLE!" It's lazy in the most dangerous way, where we're lulled into a false sense of safety and security instead of checking and re-checking our documentation for errors. You know how when you proofread your writing certain mistakes and typos stand out only after very close analysis? We're too familiar with ourselves and it's too easy to think that even a single read-through or two is enough to catch errors.

Because it's not. Especially on a screen. Especially when the only things moving are your eyeballs, when you've got over a dozen, perhaps more than twenty, patients to see, and you'd skipped lunch and it was fucking Meat Lasagna day, and you got into a fight with your partner this morning after you came home from work last night.

And when the entire goddamn EHR program uses Arial nearly everywhere, and readability is totally shit. I supposed it could be worse. It could be Comic Sans (this is possible. I just checked).

BUT THERE ARE A LOT OF GREAT THINGS ABOUT EHRs THAT REALLY CAN PREVENT ERRORS
If the documentation of things is truly accurate, then EHRs can be immensely powerful. For all the crap I've spewed about Epic, it's possible to use it in such a way as to take advantage of it. To do so requires a lot of time. Time to update and verify information already in patients' records, and time to forge one's own way within the program: I had spent months setting up custom macros and templates for my group and designing a workflow that had everyone's input. I spend a lot of time showing them tips and tricks most of you probably already know, such as recognizing that some LCD monitors are shit when viewed off-axis, and that Brightness and Contrast controls exist and are useful. Or how to insert photos, imaging, or any other graphic into a note. Or that hitting CTRL-TAB easily switches between browser tabs, making it ridiculously simple to compare things like different EKGs and chest x-rays a snap.


Or that, yes, while this particular EHR program is shit and looks like shit and is built atop a mountain of shit that connects with a shit mountain range, the first error in medicine is to think that we are infallible. The second error is to believe that we stand alone and smartly in our white coats.

We are part of a team, and all of us have a duty to the patient, and the patient is part of the team as well. The idea of physicians being of a special class, or triple-O and godly, is so damn tiresome. Let's not come across such things like this tragedy as mere spectators, but as scholars. And let us watch out for one another and feel no worry about catching any mistakes, or shame for not knowing or in learning.


It's pretty amusing to read about this, as it is reading about the recent sea-change in the approach to pain management and narcotics. Neither of the two, and none of what I wrote above, strikes me as surprising. And that's terribly disappointing and sad to me.
posted by herrdoktor at 9:44 PM on May 6, 2016 [42 favorites]


Regarding the work hour limits, there was a recent randomized control trial examining work hour restrictions for general surgery residents (post-graduate medical trainees), and there was in fact no difference in patient care quality measures when you compare programs where residents with strict work hours rules and those who adhered to a more flexible schedule, but which had less rest between shifts. (There is actually an ongoing RCT study, the "iCompare" trial, examining this question of the effect of work hours on patient care quality/errors for internal medicine residents.)

Work hours restrictions sound like a good idea but in practice, as it is implemented now, does not make a meaningful difference in the outcomes of patients as studied in general surgery residents. In fact, in my view, work hour restrictions hinder GME/residency training. It makes patient care more like shift work, but in reality, ongoing patient care is not at all like shift work. While being on duty for 36 hours straight sucks, you see in a very direct manner how your decisions on-duty, affect patient management. The shift-work attitude also reduces the incentive for some residents to take full responsibility for their patients, off loading work to the covering resident who may not be as familiar with the patients. In these hand-offs or transitions of care between providers, errors may occur. This shirking of responsibility through the shift-work mentality is not something you want the next generation of physicians to internalize.
posted by scalespace at 10:37 PM on May 6, 2016


I am completely unsurprised by this. Medical mistakes killed my grandmother at one of the most reputable hospitals in the country, killed my grandfather at a less reputable but still decent hospital, are in the process of killing my father, and almost killed me and my mother's best friend for different reasons. Like, I know more people who have suffered seriously (or died) due to medical errors than people who haven't experienced this. I do not trust hospitals or medical professionals at all.
posted by xyzzy at 1:54 AM on May 7, 2016


Iatrogenesis is the reason we have the Hippocratic Oath.
posted by lkc at 4:03 AM on May 7, 2016


Scalespace- the study you linked to notes that "Both groups had to adhere to the ACGME mandated 80 hour work week, number of days off, and frequency of call regardless of group assignment."

So this study was just comparing how the 80 hours is divided up. It did not compare one group working 80 hr weeks and another working 60 hrs, or 120 hr weeks or whatever. Therefore, I think that you are overstating the conclusion when you write that "Work hours restrictions sound like a good idea but in practice, as it is implemented now, does not make a meaningful difference..." Both groups were restricted in the number of hours they could work. A more accurate statement might be "This study finds that the way that weekly hours are divided has no effect on patient outcome."

And actually, the authors note that when it comes to outcomes such as failure to rescue (death after a treatable complication), renal failure and post-op pneumonia they could not conclude that the flexible group was "non-inferior" to the strict group (though they do note that the flexible group did not have statistically significant higher rates of these outcomes).
posted by brevator at 8:11 AM on May 7, 2016


I could have been more explicit about "work hours restrictions" and I did not mean to imply that I was referring to restricting work hours e.g. 60 vs 80 vs 120. The ongoing debate is whether the changes made in 2011 by the ACGME has any impact on patient care and on residency-training related outcomes compared to the previous changes made in the early 2000s with the 80 work hour limit.
posted by scalespace at 10:02 AM on May 7, 2016


The hours worked by medical staff have always bothered me, knowing how I function after 8, 12, and 24 hours of work. But having a mother who was a nursing instructor means I have always known a lot of nurses who always defend their hours. They may work 12 hour days, but they only work 3 days a week! So really they get plenty of rest. In fact, it's so damn convenient, many of them work two full-time jobs at once! Wait, what was that about rest?

I used to work mental health crisis on-call, in addition to a regular 40 hour a week job. I often spent 8-12 hours at a time overnight in the ER. On the one hand, it was a little reassuring knowing the doctors were actually asleep most of their shifts (it was a quiet ER, barring horrible accident, most night shifts required little input from the doctor.) On the other hand, knowing the docs were making calls and ordering scripts sometimes literally from bed while dozing was a little worrying.

Also I used to have to call in sick to my job after being up 24 hours doing crisis work. 24 hours was my limit of "being awake and still being expected to make life and death decisions about people." My bosses, of course, would have preferred I come to work anyway.
posted by threeturtles at 10:30 PM on May 8, 2016


« Older "Bruh, can you not?"   |   Sand ...sand ...sand Newer »


This thread has been archived and is closed to new comments