Anesthesiologist, Textbook Editor, Media Consultant
My job responsibilities have changed dramatically. My first job at age 16 was as a hostess. On a good day, I would make at least one mistake an hour. No harm done, but I was still fired after only three weeks. Two decades later, as a physician anesthesiologist, a mistake could mean the difference between life and death. And it can occur over a matter of seconds. A new study in the current issue of the Journal of Patient Safety claims that between 210,000 and 440,000 patients die each year in the hospital due to a medical mistake. That would make medical errors the third leading cause of death after cardiovascular disease and cancer. The value is greater than the number of people who die from homicide, HIV, stroke and diabetes combined. The irony is that you go to the hospital to receive care and undergo healing. The number of deaths from preventable mistakes should be zero. Instead, with approximately 34 million hospital admissions a year, there is a 0.6-1.3 percent incidence of mortality. Furthermore, these shocking statistics do not quantify injuries from medical mistakes, or indicate that every year 1.3 million Americans incur injuries due to “medication errors,” or that every day approximately seven wrong-site surgeries occur. Numerous comparisons have been made between aviation and medicine — peoples’ lives are at stake and highly skilled and trained professionals must work together to achieve safe results. Safety in the airline industry came painstakingly and was “literally bought in blood.” However, inherent differences between the two industries have made it challenging to extrapolate safety protocols. People are not airplanes. They are not manufactured on an assembly line and do not act the same every time. Where the healthcare field needs to emulate the aviation industry is in learning from its painful mistakes. The airline industry has developed a nonpunitive reporting system that also aims to shift the blame from the individual to the environment or system. Similarly, most medical errors appear to be secondary to faulty systems rather than individuals. Unfortunately, less than one-third of hospital systems allow for anonymous reporting of mistakes, allowing the possibility of backlash or retribution. A healthcare worker should never be placed in the position of choosing between political correctness or doing the right thing for the patient. The recent Asiana Airline crash was discussed and dissected by the media. The aviation industry quickly identified the root cause and already implemented system changes to prevent it from happening again. Aviation remains one of the safest forms of travel where death occurs in one out of 10 million travellers (there are approximately 32,000 motor vehicle deaths a year in the United States). Conversely, accidental patient deaths often go without notice or media attention. Following the airing of a 20/20 news segment in 1982, titled “The Deep Sleep: 6000 Will Die or Suffer Brain Damage,” the American Society of Anesthesiologists responded with a program to standardize anesthesia care and monitoring. Within two years, the new standards decreased the number of deaths from 0.01 percent to 0.0005 percent due to inadvertent insertion of breathing tubes into people’s esophagus instead of their trachea. In this instance, media coverage stimulated change and has helped save human lives. It would be absurd to have an airplane fly to the wrong destination because the pilot misread the destination. Doctors are notorious for their terrible handwriting. It would be laughable, except that bad writing can be deadly. With over 3.2 billion prescriptions written in the United States annually, sloppy penmanship contributes to 7,000 deaths a year. Many errors result from illegible writing, ambiguous abbreviations and dosage indications. To address this problem, electronic prescribing programs have been developed. But until recently, doctors have not embraced this system due to the cost. Fortunately, The National e-prescribing Patient Safety Initiative (NEPSI) now offers doctors access to eRx Now, a Web-based tool that physicians can use to write prescriptions electronically, check for potentially harmful drug interactions and ensure that pharmacies provide appropriate medications and dosages. The goal is to do away with the prescription pad, a weapon of mass destruction, and start providing incentives to physicians who embrace it. Lost baggage during traveling is inconvenient and a nuisance. However, leaving behind instruments, sponges or needles in a patient—known as “retained surgical items” — following a surgery or procedure can result in significant suffering, harm and death. This should be a “never event,” but unfortunately it is estimated to occur between 4,500 to 6,000 times a year. At the end of a procedure, counts are conducted. However, the lack of standardization creates opportunities for errors. Manufacturers now make sponges that can be tracked. These sponge-tracking systems can cost between $8-$12 dollars an operation, but many hospitals just have not adopted the system due to the overall cost of thousands of surgeries. There are obvious differences between the airline and healthcare industry. However, one thing we can learn is that analyzing mistakes can help to prevent, monitor, and respond to them and thereby change standards of care. The common goal should be to save lives and decrease harm, and as an added benefit lower costs and liability.