Often times a book like Internal Bleeding is written primarily from a third or fourth person point of view in an effort to inform the American public about something that occurs thousands of times each day in hospitals all over the country. This book however, was written by two doctors, Bob Wachter and Kaveh Shojania, whose real-life accounts of near-miss mistakes could have ended in tragedy, and even more interestingly; their cases happened ten years apart from each other. Robert M.
Wachter, a young doctor at the time learned the hard way about ambulances and priority numbers. Kaveh G. Shojania, a resident at his time misdiagnosed a heart attack for rib trauma and gastritis. Wachter and Shojania share a mix of horrifying medical accidents throughout the country by residents and seasoned veteran doctors, and the research that explains what needs to be done to fix or remedy the problems. In chapter four we learn of many popular medications and how remarkably they have similar names.
The antidepressant Zyprexa and the antihistamine Zyrtec; the anticonvulsant Cerebyx and the anti-inflammatory Celebrex; and the mood stabilizer Lamictal and the antifungal Lamisil are but three of the many examples where even good penmanship is no substitute for an alert and functioning brain in those who write and fill those prescriptions. Other medication misadventures include: when a drug is used improperly, or when a doctor miscalculates and prescribes an excessive dose, or when the pharmacist misreads a scrawled prescription and prescribes the wrong medicine.
Oliver Wendell Holmes (1860) stated it best “…I firmly believe that if the whole materia medica (list of available drugs) could be sunk to the bottom of the sea, it would be all the better for mankind – and all the worse for the fishes”. The use of computerized physician order entry, or CPOE, could potentially eliminate most of the medication errors that occur at the prescribing and order-filling stage. Prescribing doctors can override CPOE suggestions, and sometimes they should. But before they can veto a computerized suggestion for a substitute medicine, doctors must answer “are-you-sure? type of prompt. “This may not make health care faster or cheaper than it is now, but it will certainly make it safer” (Wachter & Shojania, 2004). Unfortunately, the vast majority of U. S. hospitals still lack any form or CPOE system. Transferring data from one hospital to another and cost are barriers associated with such a system. The most overwhelming hindrances are organizational passivity and resistance to change. “Ultimately, computers will help treat our epidemic of medical mistakes, but they are not a cure-all” (Wachter & Shojania, 2004).
In chapter seven, “Of Life and Limb”, Wachter & Shojania go on to describe the horrific story of Willie King; the fifty-one year old diabetic with three kids whose life changed dramatically when the doctor amputated the wrong leg. And the story of Rajeswari Ayyappan who had a tumor on the left frontal lobe of her brain, but the doctor spent hours chiseling through the right side. Both the Willie King and Ayyappan cases involved identification problems. In the first, it was the wrong site; in the second, it was partly the wrong site but also the wrong patient.
Since orthopedic surgeons are most likely to perform wrong-site procedures, that field has led the fight against the most outrageous of errors. Dr. Harvey Cushing, the pioneer of modern neurosurgery quoted, “…I would like to see the day when somebody would be appointed surgeon somewhere who had no hands, for the operation part is the least of the work”. In 1994, the Canadian Orthopaedic Association launched a campaign to “Operate Through Your Initials”, followed four years later by “Sign Your Site”, sponsored by the American Academy of Orthopedic Surgeons.
Both organizations urged surgeons to initial the intended operative site, using a permanent marker, during a scheduled preoperative visit. “Where these programs have been systematically applied and consistently enforced, the results have been good and promise to get better” (Wachter & Shojania, 2004). Wrong-patient and wrong-limb errors, while horrifying and unacceptable, are to some extent understandable given the chaos of the health care universe. They say that “practice makes perfect”, but this is not always the case as written in chapter nine.
In chapter nine Wachter & Shojania state “…what is faced in every operation, are issues regarding each caregiver’s judgment and technique”. Aside from the obviously outrageous, and therefore uncommon, instances when a particular surgeon’s sutures keep coming undone or his scalpel repeatedly slices through major blood vessels, second guessing the real-time actions of highly trained professionals is very difficult. Health economist Harold Luft (1979) wrote an article in the New England Journal of Medicine about the simple principle that practice might just make perfect when it comes to surgery.
Centers that perform more operations of a specific type such as; coronary bypasses, other vascular surgeries, prostate resections and hip replacements enjoyed better outcomes. The authors state that it may surprise us to learn though that the relationship between volume and outcomes is more tightly linked to number of procedures in a particular hospital than by a specific doctor. The author reflects on the idea “… perhaps the outcome is better because of the high volume of surgeries, or do volumes increase because word-of-mouth spreads the news about better outcomes” (Wachter & Shojania, 2004).
Practice does make perfect, but only if the physicians start out knowing what they are doing. High-volume and good outcomes tend to go hand in hand if the providers are already skilled. A too-crowded hospital eventually creates an error-prone, overworked staff. While studies looking for this effect have generally not found it yet, a comprehensive across-the-board policy shift designed to push patients to high-volume centers could ultimately cause problems, especially if the increased volume isn’t anticipated and budgeted for.
More training and more skilled doctors could relieve some issues of overcrowding hospitals because the lack of experts in the field. The authors go on to let us know unfortunately in the medical profession there are no requirements to demonstrate ongoing expertise. There is no formal training, no testing, no demonstration of competency, no apprenticeship in new techniques when it comes to recertification in the medical field (Wachter & Shojania, 2004).
Doctors must attend a certain number of continuing education courses for a certain number of hours each year towards their recertification. The picture of an ideal surgeon we envision is one of people who constantly practice their craft, practice their procedures mentally, and are their own worst critics. Achieving true excellence and freedom from errors will take much more than the efforts and guarantees of individuals, however talented, well-meaning, and committed they may be. For medicine …even the surgical part of medicine, it is a team sport” (Wachter & Shojania, 2004). In chapter twelve, we learn more about the miscommunication of staff at a hospital when a swing-shift nurse calls a “Code Blue” on an elderly man, there is no sign of a chart in his room, a physician grabs what he thought was the patient’s chart and calls this patient a DNR, or do not resuscitate, only to find out he grabbed the wrong chart after the fact. They call another “Code Blue” to try and to revive the man, but it is too late.
It is easy to blame the doctor for grabbing the wrong chart from the crowded rack and for not checking the name against the patient’s wristband but, what about the poorly trained Code Blue team, insufficient procedures for identifying patients during Codes, deficient systems for documenting advance orders in charts. I feel this situation presented by the authors gives us so many possibilities for finger pointing that we don’t have enough fingers to go around. Too many patients as well as practitioners, doctors and nurses seem like the original “odd couple”. Sometimes, they live in different universes.
For two groups that have historically and unavoidably worked closely together, there is still remarkably little understanding and appreciation of each other’s roles. Tensions grow as the nursing shortage gets worse. Nurses fear retaliation as the primary reason for not speaking up or reporting certain acts of negligence to their superiors. In a study by the University of Pennsylvania nursing professor Linda Aiken, she found that surgical patients had a thirty-one percent greater chance of dying in hospitals when the average nurse cared for more than seven patients at one time.
Clearly, we must do much more to create a collaborative culture in health care. One in which all providers at all levels feel free to report and learn from their mistakes, act in unison, and voice their concerns while there is still time to do something about them. Wachter & Shojania, 2004 go on to say, “…physicians have to see themselves in a new light; not as “captain of the ship” but as an integral part of a multidisciplinary team in which no role, or voice, can safely be ignored”. In chapter fourteen we learn of a prominent physician Dr. James Jaggers. Dr. Jaggers was one of the brightest ediatric heart surgeons at one of the Meccas for heart transplant surgeries, Duke University. Jesica Santillan was the seventeen year old girl born with restrictive cardiomyopathy, a disorder of the heart that limits its ability to accept blood from the lungs and pump it effectively to the rest of the body. Jesica was an extraordinarily high-profile case, and both the doctor and his staff undoubtedly felt crushing pressure to find a suitable donor. Death takes people in nasty ways, and donor organs must not only be undamaged by trauma, they must be free of the disease that killed the previous owner.
For pediatric transplants, the organs must also be of a size that fits the recipient, which is often the most challenging match of all. There is a procedure that takes place by the United Network for Organ Sharing, or UNOS computer which identifies donor matches based on the computers database and notifies the appropriate organ service centers when a match is found. The UNOS computer identified a child at Duke (that was not Jesica) who seemed to fit the criteria, so the Carolina Donor Services got Jaggers on the phone.
Jaggers was elated to receive that middle-of-the-night phone call informing him a dying donor with organs had been found. Jaggers declined the organs for a patient on the list because he said “…the boy was too sick, but Jesica who was not even on the list was a perfect candidate”. The next step would have been for the CDS to confirm the blood type match, but for reasons unknown they didn’t. Jesica blood type is O and the donor’s blood type was A, a critical error that ended in Jesica’s death and perfectly good organs that could have been used to save another child’s life.
Like so many medical errors, this one occurred because people were so focused on the big picture that they completely overlooked the small stuff. Jesica’s case turns our attention towards how we deal with consequences of medical errors and the additional lessons to be learned. How, when, or even if caregivers should tell patients and families about these mistakes; whether to tell the media; and whether regulatory agencies should be involved are just a few. In Jesica’s case these issues all arose at once and with hurricane force.
In the end, a case like Jesica’s, and its media coverage, helps make health care safer, through both the lessons it teaches and the resources it generates. “Everyone will be famous for fifteen minutes” was said by Andy Warhol (1982 – 1987). I don’t think this is the kind of fifteen minutes of fame Dr. Jaggers was hoping to receive. We are left with conflicting emotions over the Duke case, its disclosure, and the subsequent media coverage; tremendous sadness over Jesica’s death; sorrow over the wasted organs of her young donors; general praise for the media for taking up the cause and pushing forward the safety agenda; and sympathy for Dr.
James Jaggers, who will be remembered not for his selfishness, his skills, and his dedication, but for a late-night blunder that wasn’t caught by a faulty system. “A blunder that served notice that he was human; nothing more, but quite certainly nothing less” (Wachter & Shojania, 2004). Say “medical mistake” to a physician and the word you get back in malpractice. This trained response is the product of decades of experience. In our market-driven, controversial society, the malpractice system scars the health care landscape like the charred remnants of a lava flow.
We’ve already seen that most errors in medicine arise from situations in which the provider is not strictly “at fault”. Here we define fault as an act that could have been prevented, but wasn’t; or an act that should have taken place, but didn’t. Most errors involve slips or glitches in automatic behaviors that can strike even the most conscientious practitioner in any field. Slips by definition, are unintentional, they are something like a force of nature; they cannot be dissuaded by threat of lawsuits. A malpractice culture also forces doctors to view every patient as a potential litigant.
Since the late 1980’s the studies of Harvard lawyer physician Troy Brennan and his colleagues have convincingly proved that our “ugly social system” of malpractice litigation leaves much to be desired. Brennan’s studies of malpractice claims in three states show that doctors have a more than 1-in-100 chance of being tagged with a lawsuit after a patient has an adverse event, even when the doctor has done nothing wrong. Of course, while awards or settlements help bring closure for patients and families, their effects can linger for physicians.
It is inevitable that doctors’ insurance premiums immediately will go up and they must report the settlement every two years when they renew their clinical privileges at the hospital. With the talk of justice aside, a more practical and political issue presently dominates the malpractice debate; the cost of awards, and of coverage. The average medical malpractice judgment runs about one million dollars and twice that for cases related to childbirth. The present “malpractice crisis” has led, once again, to occasional attempts to pass malpractice reform legislation, most of them aimed at the U.
S. Congress. The debate in 2003 was over proposals to cap pain and suffering awards, “…the highest paying ticket in the malpractice lottery” (Wachter & Shojania, 2004). Hospitals can be dangerous places. Media reports of medical errors would lead us to believe that the problem is relatively straightforward and could be solved if all the errors were reported to newspapers and to regulators, bad-apple physicians, nurses were eliminated, and sleep-deprived residents and interns were allowed to get a little shut-eye. The problem is that these simple-minded analyses and solutions are largely wrong” (Wachter & Shojania, 2004). The authors go on to tell us “…most errors are made by good but fallible people working in dysfunctional systems”, which means that making care safer depends on strengthening the system to prevent or catch the inevitable lapses of mortals. “Systems thinking”, by which means a carefully developed and applied set of rules, standards, checklists, technologies, and training programs that helps good caregivers give good care and prevents them from unintentionally harming their patients.
Medical errors are a hard enough nut to crack that Wachter and Shojania both agree “…we need excellent doctors and safer systems”. Together they convincingly argue that a flawed hospital system, rather than flawed individuals, is responsible for the thousands of deaths that result from medical mistakes each year. Upon opening this book and reading the first chapter was enough to make me nervous and uneasy about stepping foot in a hospital, or having a doctor make a determination about my health.
Each chapter starts with a story which captures the reader’s attention. The authors present case studies of various types of medical mistakes, emphasizing why they happen; describe ways society reacts to mistakes, especially dramatic cases and conclude with recommendations for change. Overall, Wachter and Shojania shed light on a lot of issues that go unnoticed and undocumented on a daily basis. Sadly, before reading this book and learning of all these mistakes I was much happier living in the dark.
