To Err is Human

I am attending the First ASEAN Patient Safety Congress next week June 25-26. The theme is Towards a Unified Approach to Patient Safety: The ASEAN Perspective. A colleague will be presenting our work in the medication error study group. Then I saw this on my Twitter feed –

My first thought was, is there Philippine data? ASEAN data? I guess I’ll find out next week at the congress. As a health informatics student, I was asked to read the Institute of Medicine’s To Err is Human: Building a Safer Health System. This statistic is often quoted from this document –

Health care in the United States is not as safe as it should be–and can be. At least 44,000 people, and perhaps as many as 98,000 people, die in hospitals each year as a result of medical errors that could have been prevented, according to estimates from two major studies.
Even using the lower estimate, preventable medical errors in hospitals exceed attributable deaths to such feared threats as motor-vehicle wrecks, breast cancer, and AIDS.
This document is a lesson taught in health informatics because there are of course technology-based solutions to preventing medical errors. I just had to smile when I saw this quote –
To err is human; to really foul things up requires a computer.
Bill Vaughan
What is a medical error? The definition below is from Grober ED & Bohnen JMA, Defining medical error. Can J Surg 2005; 48(1): 39-44.
Medical error: an act of omission or commission in planning or execution that contributes or could contribute to an unintended result.

The #HealthXPh tweet chat on June 20 Saturday 9 pm Manila time will focus on the following questions: T1 How can healthcare professionals prevent medical errors? Have you seen the Swiss Cheese model of James Reason? It says that patient comes to harm only when holes in the layers of defense line up.

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I think that both physicians and patients (there are other players of course) form part of these layers of defense. Hence T1 and T2 ask how both can help prevent medical errors. I was particularly distressed by Eric Topol’s estimate of 12 million serious diagnostic errors. The AHRQ Patient Safety Primer has classified cognitive bias that lead to diagnostic errors:

  • Availability heuristic: diagnosis of current patient biased by experience with past cases
  • Anchoring heuristic (premature closure): relying on initial diagnostic impression, despite subsequent information to the contrary
  • Framing effects: diagnostic decision-making unduly biased by subtle cues and collateral information
  • Blind obedience: placing undue reliance on test results or “expert” opinion

T2 How can patients prevent medical errors? Check out 20 Tips to Help Prevent Medical Errors, a patient fact sheet by the Agency for Healthcare Research and Quality (AHRQ). T3 How should healthcare professionals disclose medical errors to patients?

To err may be human, but to admit it isn’t.

Herbert V. Prochnow

I think this is not taught often enough in medical school. Dr. Kelly Fryer-Edwards of the University of Washington School of Medicine has written Tough Talk: Helping Doctors Approach Difficult Conversations. A toolbox for medical educators. It has a module Talking about Harmful Medical Errors with Patients. In this module, Dr. Kelly enumerates the ethical rationale for disclosing medical errors.

  • Informed consent. Error disclosure is necessary for the patient to make decisions about subsequent care.
  • Truth-telling
  • Justice and fairness

More importantly, Dr. Kelly also lists the elements patient prefer in error disclosure.

  • An explicit statement that an error occurred
  • What the error was and the error’s clinical implications
  • Why the error happened
  • How the recurrences will be prevented
  • An apology

I was traveling and have missed several #HealthXPh tweet chats. Looking forward to chatting with you all on June 20!

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