250,000. That is the number of deaths from medical error calculated in a study by patient safety researchers at Johns Hopkins. That would make medical error the third leading cause of death in the United States, outnumbered only by heart disease and cancer. Medical error is a problem that can affect anyone. Unfortunately, this doesn’t get the same amount of attention as other issues facing health care. Comparing medical error to the current drug epidemic in the United States, the Johns Hopkins report would put the death toll from medical error at 3.5 times the number of individuals killed by drug overdoses in 2016. However, thanks to great work being done by groups like IHI and AHRQ, as well as patient safety researchers, there are steps the health care industry can take to reduce medical error.
It is worth saying that Johns Hopkins’ estimate of 250,000 isn’t without criticism. Health care systems in the United States differ dramatically by location and finding a reliable estimate of the number of patients severely affected by medical error is no easy task. This difficulty is compounded by the fact that the Centers for Disease Control and Prevention (CDC) does not register medical errors as a formal cause of death and that the causes of medical error are hard to solve. Studies have found that common causes of medical error include fatigue, inadequate supervision, inadequate experience, and faulty communication. These causes are often institutional failures and can't be addressed by simply flipping a switch. So, what can be done in the face of a problem with such a broad scope and no single solution? And what can an individual practice do to start addressing medical errors in their own backyard?
One example of something hospitals could do to begin addressing this issue is to implement common sense systems to catch errors before they affect a patient. For example, medication errors, a common source for medical error, can be dramatically reduced by implementing systems like Barcode Medication Administration (BCMA), where a doctor or nurse scans the medication before giving it to the patient. This simple step gives the computer a chance to check the provider’s work. But, it isn’t necessary to implement new systems that can cost a practice thousands of dollars a year. For smaller clinics, simply applying “Do not Disturb” rules whereby those administering medication are able to work in a quiet place, free from interruption, was shown to reduce the error rate of those administering medication by roughly the same amount. Another key focus of patient safety research is patient handoff. Because of the complexity and variety of patients’ conditions, patient handoffs must adjust to fit the patient's situation and do have the potential to be a large source of communication errors. However, one study looking at patient handoffs found that implementing a mnemonic device, called I-PASS, to guide physicians through patient handoffs reduced adverse events by almost a third. Simple changes like using the I-PASS method are inexpensive and are designed to ensure that all critical patient information is communicated effectively and in a timely manner. Implementing these changes doesn’t have to come at the cost of reducing the quality of patient care. The same study found that there was no increase in time spent conducting patient handoffs and there was no decrease in time spent with patients.
Humans are prone to making mistakes, and doctors are no exception. One report says that rather than blaming individuals for mistakes, institutions can create a culture of safety in the workplace and design their systems to protect patients, making patients safer while unburdening doctors with the stress of being one simple mistake away from being on the bad end of a tragic statistic. pMD is proud to work with health care teams to promote communication in the hopes of preventing medical error and improving patient care.