Blog | Tuesday, August 23, 2016

How to make medicine safer


I have 2 very inquisitive sisters, and they've raised 4 inquisitive children. I give them full credit for this, although my parents must have had something to do with it, as in 7th-grade math I won an award for my “unique ability to question the trivial.”

Of course, trivial is in the eye of the beholder. Sometimes the trivial questions are the hardest, like: “What is 0?”

One of my sisters asked me a not-so-trivial question a few years ago:

“So, as a doctor, are you ever worried that you'll make mistakes?”

“No,” I answered, “I know I'm going to make mistakes.”

This is something other industries such as airlines have understood for decades. Medicine is only starting to learn what this means. Throughout our training, we are taught over and over to double- and triple-check our work. We devote hours and hours to memorizing drugs and their interactions. But we aren't taught how mistakes really happen, or even that they do. We are taught that mistakes are not inevitable, are a sign of personal failure and that only our own actions can prevent them.

This is very, very wrong.

Several years ago, a professor from Johns Hopkins, Dr. Peter Pronovost, realized that individuals make errors, and came up with an idea to improve systems so that the imperfections of individuals will matter less.

The Keystone project is simple and made immediate, measurable improvements in patient care. For example, the rate of infections of IV lines in ICUs dropped to essentially 0 soon after implementing Keystone.

And what was this enormously successful intervention?

A checklist. In brief, in non-emergent placement of IV lines, nurses are given the authority to make sure doctors follow a brief, simple checklist, and to stop the procedure if it isn't followed. The program also educates clinicians on the basics of preventing line infections and makes sure the need for an IV line is reassessed daily so that they will not be left in unnecessarily.

These relatively simple system changes have been made successfully in other hospital settings, but are not yet truly a part of medical culture.

In the U.S., medical care is fragmented. My patients often ask me why I don't have access to their electronic records. The answer is simple: Different doctors and hospitals use different systems, and these systems don't talk to each other. The technology exists, but our culture hasn't realized the importance of it.

If I were able to look up any patient of mine and see every test done, every medication prescribed, their care would be safer. But this simply isn't done, and the reason is cultural. In the U.S. we are afraid of anything that smells of “socialized medicine” and anything that might violate our medical privacy. These aren't trivial concerns, but they ignore the fact that as healthcare becomes better, it also becomes more dangerous. Detractors love to cite statistics about how many deaths in the U.S. are attributable to the health care system, but this distracts from the real problem. Modern medicine improves lives. And people in hospitals are very, very ill compared to the past.

Even when we get to the point where Keystone-like systems are the norm and sharing of medical information is automatic, people will be injured and die in hospitals because that's where we go when we're sick. People don't die at Wrigley Field because they don't go there for their cancer or heart disease.

“Have you washed your hands?” seems a trivial question, but it turns out to be life-saving. Individuals easily forget, but a system designed to ensure your compliance saves lives.

Peter A. Lipson, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. After graduating from Rush Medical College in Chicago, he completed his internal medicine residency at Northwestern Memorial Hospital. This post first appeared at his blog at Forbes. His blog, which has been around in various forms since 2007, offers "musings on the intersection of science, medicine, and culture." His writing focuses on the difference between science-based medicine and "everything else," but also speaks to the day-to-day practice of medicine, fatherhood, and whatever else migrates from his head to his keyboard.