To Err is Human
Research Article Written By: Connie J. Perkins, PhD, RN, CNE and St. Bonaventure University Honors Students Jacob Schoeberl, Alexandra Rozanski, Andrew Campbell, Abbigail Cloud.
But to REALLY screw up, throw in an electronic health record.
Safety in the healthcare field has always been a topic of discussion. However, it was not until 2000 that the book To Err is Human identified and spotlighted numerous dangerous issues within the healthcare system that there was a national call to action to make health care safer. Since then, there has been extensive progress made in the field of medical error identification and prevention thanks to the efforts of many leaders in the healthcare field. The concept of medical error prevention is prevalently featured throughout healthcare education by way of discussions, trainings, classes, and simulations.
IF ERRING IS HUMAN, HAVE
COMPUTERS MADE THINGS SAFER?
Rarely discussed in these medical error prevention forums, however, is an embarrassing paradoxical secret: medical mistakes are STILL occurring, and perhaps at an alarmingly increasing rate. One would assume that the application of technology would have healthcare delivery more efficient, less costly and safer, but in many circumstances, the exact opposite has occurred.
The widespread rapid introduction of electronic health records in the healthcare industry within the past decade is causing a form of human fatigue and burnout that is actually putting patients at increased risk instead of protecting them.
EHR’s have produced a multitude of unintended burdens on clinicians.
Health Information Technology was not instituted with the end-user in mind. Well-intended processes and checklists that were implemented to help protect patients may have worked well pre-EHR, but they have only served to frustrate clinicians who went into medicine because they wanted to interact with humans, not with keyboards.
Many of the processes that hospitals had put in place after To Err is Human was published in 2000 to protect patients and keep them safe did not take into account the mayhem that Electronic Health Records (EHR) would cause.
EHR’s were designed and built for billing and coding and were never designed nor intended to be useful for the delivery and documentation of safe healthcare. Overnight, bedside nurses and physicians were transformed from critical thinking healthcare professionals into glorified data entry clerks. Meaningful interactions with patients were interrupted by the constant need to ask and re-ask their name and date of birth (in order to ensure that patients were not inadvertently given one another’s medication). Instead of looking a patient in the eye while taking a history or doing a physical, physicians and other clinicians are intimately interacting with their keyboards and dot phrases.
HOW FAR WE’VE COME AND HOW FAR
WE STILL HAVE TO GO
Are we, as the United States, ready for the sequel to the turn-of-the-century landmark book? More than 2 decades later after its landmark debut, Dr. Donald M. Berwick, one of the authors of To Err is Human, emphatically thinks that the answer is an emphatic “NO.” There, are, however, some steps that we can take in order to truly tackle the complex issue of medical errors and patient safety:
DEMAND TRANSPARENCY FROM THE
Unfortunately, medical errors are the third leading cause of death in the United States (Johns Hopkins Medicine, 2016). Information like nosocomial infection rates, readmissions, deaths, and complications that play a role in this huge number are made available thanks to entities like Hospital Compare and Leapfrog. Patients are now able to make informed decisions about where to get care.
Data is provided for facilities to analyze what they are doing well and what they need to do to improve compared with other healthcare agencies. Suggestion for improvement: Why do patients have to go to Hospital Compare or Leapfrog to see this data (which, by the way, is very outdated by the time it is published)? Hospital administrators are the ones who have access to this data and are the ones who provide the information to reporting regulatory bodies...so why don’t they instead report their data “live” on their own websites for patients? Transparency is key to establishing trust between the patient and the provider. Trust needs to start at the very top of the
proverbial organizational food chain.
INCLUDE BEDSIDE CARE PROVIDERS
INPATIENT SAFETY COMMITTEES
Medications and treatments are an essential aspect of the healthcare system. Preventable errors can occur at any point in the medication process from prescription to distribution and education. Examples of medication errors can include incorrect drug, dose, patient, labeling, as well as overlooked drug-drug interactions.
Shockingly, the Academy of Managed Care Pharmacy (2019) reported that 1.5 million people every year are harmed because of preventable medication mistakes. In addition, emergency departments receive roughly 700,000 patients yearly because of adverse drug events (Agency for Healthcare Research and Quality, 2019).
Furthermore, reported adverse drug events more than doubled from 2013 to 2018 much after the publication of To Err is Human (Baah, 2020). While hospitals have come some distance by having patient safety committees and policies, are they truly meaningful? Are the incentives truly incentives or just a method to “break-even”? Suggestion for improvement: Funds need to be allocated to pay for the cost of bedside health care workers to join and run patient safety committees. Continuing to mandate hollow committee assignments to healthcare workers who already have a lot on their plates is counter-productive to advancing true patient safety reforms.
STANDARDIZE REPORTING OF
The reporting of errors, and the process by which they are reported, varies between states. In the State of New York, for example, error reporting is mandatory (New York Department of Health, 2018). However, because of the many different reporting agencies and systems, the way that errors are coded and reported are not clear, and there are overlapping reporting systems that have confusing coding systems. For instance, if a patient dies or has serious injuries such as an adverse event, it is coded as “915” (New York Department of Health, 2018).
However, not everything coded as “915” is the result of an error. This ambiguity doesn’t allow for a proper root cause analysis to be performed. Furthermore, the questions can be subjective, making finding the root cause even more difficult. There should be one reporting system that is very clear and root cause-focused - “what happened and what circumstances
led up to the error occurring?” Let one designated government entity determine what “code” it falls under and let healthcare agencies focus on the root cause to prevent future errors.
The systems should also be anonymous since the point of reporting an error should've to prevent the error from occurring in the future, not to punish or shame a healthcare professional for a mistake that anyone could have made.
ELIMINATE THE MANY COOKS IN THE KITCHEN
There are at least 10 different organizations that regulate healthcare in the United States. These systems are all intertwined and responsible for various patient safety data collection, regulation, and knowledge dissemination (see chart). Since there are so many different organizations, some collecting information, and some disseminating information, it leads to unnecessary documentation time for healthcare workers, as well as an abundance of unnecessary information. Information that sometimes gets lost in translation.
On average a doctor will spend 16 minutes and 14 seconds documenting after every single patient, and for every hour with a patient, there are two hours of documenting (Young, 2016). It is also difficult to remember what gets documented where and where to find resources regarding patient safety practices. Further problematic, this type of documentation is in addition to the patient record documentation done after seeing a patient. Regardless of the amount of time spent documenting for either reason, errors occur because documentation systems don’t communicate with one another. As a result, unbelievably serious errors have occurred (such as failing to report a fatal brain tumor to a patient or oncologist). (Schulte & Fry, 2019)
It is necessary to have a more simple way of documenting all of the various required information in one system, and there has to be a more efficient process in place to make real progress. One organization should handle the data collection and dissemination of medical error information rather than several. For instance, instead of having the Centers for Disease Control and Prevention (CDC), the Food and Drug Administration (FDA), and Occupational Safety and Health Administration (OSHA) all collecting and disseminating patient safety data, one agency should be appointed to handle both. This would also allow for healthcare professionals and administrators to have one source to go to when looking for information rather than several.
The same system that healthcare professionals use to document patient care should also be used to collect data for reporting. Optimally, that one system should also be used from inpatient to outpatient services, further removing the window of error that can occur with paper records being lost or electronic systems not communicating.
To learn about the recommendations for future research, implemented changes, and see graphs from the research, purchase a full subscription to the PRINT version (Volume 7 Print Edition also available on our "SHOP" page) of Physician Outlook Magazine.In the Spring of 2021, St. Bonaventure University offered an Honors Special Topics course focused on Medical Error in the United States. The course required Honors students to critically review the landmark publication To Err is Human by the Institute of Medicine (IOM) which is now called the National Academy of Medicine (NAM). Lessons, assignments, and discussions focused on the recommendations listed in the publication. Students studied how to prevent medical error to see how far the United States health system has come and just how far it still needs to go. Students also spent time emailing assigned preceptors currently practicing as a healthcare professional within the community surrounding the university. Preceptors included a Registered Nurse, a Pharmacist, a Physician Assistant, and a Respiratory Therapist. Students used these preceptors to confirm or deny current practice, professional resources, and principles found during in-class research. Students then presented to the class how the preceptor prevents medical error in today's healthcare system and an action plan for how preceptors can do more. Students also assumed their researched healthcare role during a simulated code event focusing on high-stress environment medical error. The findings and discussions were particularly enlightening due to all students being undergraduate and not currently enrolled in a license-qualifying program (i.e., RN, PA, OT, MD). Many shared stories of personal experiences as a patient or support person during and in class research.
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