FEATURE
Medical Mistakes
unexpected happens, they are prepared.” He antici-
pates that a majority of institutions will have a CRP
in place within the next few years.
The Errors of Others
Standardized CRPs among health-care facilities
may help solve the problem of “pre-referral errors”
or “interfacility medical errors” – mistakes that are
picked up by downstream providers from different
organizations.
When errors are identified by providers who
work in the same facility, there are clear ways of
revealing and managing these issues: incident
reporting, patient safety committees, root cause
analyses, etc. Those mechanisms simply don’t exist
between different facilities; there are no clear profes-
sional norms regarding disclosure when physicians
discover errors that were made at other institutions.
“This is really not a problem that’s ever been
explicitly defined or described in the literature,
and there are no guidelines for what to do in these
scenarios,” said Lesly Dossett, MD, MPH, assis-
tant professor of surgery in the division of surgical
oncology at the University of Michigan.
Dr. Dossett has been exploring this gray area
in her research. Her interest in this type of medi-
cal error was born during her clinical fellowship at
a major cancer center, when she noticed how often
cases of mismanagement and misdiagnosis would
come up during tumor boards.
“Everyone would sit around discussing cases and
say things like, ‘Wow, who would ever do that?’” she
related to ASH Clinical News. “And I noticed that
nobody disclosed the conversations to the patient or
provided feedback to the referring physician. That
bothered me.”
When she delved deeper, she found that special-
ists, in particular, seem to struggle with these conver-
sations because they are unsure about what to do and
they are uncomfortable providing negative feedback.
Dr. Dossett said she was most intrigued by the
fact that surgeons felt reticent to “project superior-
ity,” according to interviews of cancer specialists from
two National Cancer Institute–designated Cancer
Centers. 10 “We’re specialists, which means we have
years of extra training to be able to deal with those
rare problems, and that’s why the patient was referred
to us in the first place,” she said. “Yet, we don’t want
to alienate our referral base, even when dealing with
rare problems that generalists would not be expected
to have much experience with.”
Most specialists who participated in the interviews
also expressed the belief that disclosure of medical
errors “provided no benefit to patients and might un-
necessarily add to their anxiety about their diagnoses
or prognoses.” They often did not reveal mistakes to
patients or only partially revealed mistakes.
“Some participants expressed the belief that
disclosure should come from the responsible physi-
cian,” the authors reported. But, paradoxically, most
respondents also noted that, “in many cases, they
did not believe the responsible physician was aware
of the error.”
Interfacility errors aren’t just misses by referring
physicians; they can take many forms, Dr. Dossett con-
tinued. “It can happen when, say, I operate on some-
body and forget to restart the anticoagulant before I
discharge him or her. The patient has a stroke and ends
up in an outside emergency department,” she said.
“It’s the same type of problem and somebody needs to
provide feedback to me that we made an error.”
When Dr. Dossett and colleagues queried 30
specialists heavily reliant on external referrals about
this issue, they learned that few respondents prac-
ticed regular, explicit feedback, despite recognizing
its importance. 11 Some cited time limitations and
other structural barriers as obstacles, but the main
barriers to providing feedback involved psychologi-
cal discomfort, like fear of conflict, negativity, and
jeopardizing future referrals. Medico-legal uncer-
tainty and risk were also cited as hindering factors.
“After conducting a comprehensive review of
all the federal and state laws in Michigan to see if
there would be any case law that would support a
requirement for feedback, [we] found no case law
that would justify a requirement for disclosure,” she
added.
Joseph Jacobson, MD, MSc, chief quality officer
at the Dana-Farber Cancer Institute, said he only
occasionally sees examples of pre-referral error of
the type Dr. Dossett is studying but agreed that there
is no structure or requirement for reporting such an
event. “As far as I know, it doesn’t trigger a report to
our board of registration in medicine or our depart-
ment of public health,” he said.
Dr. Dossett’s team also reviewed 130 ethics
codes from large health-care societies like the
American Medical Association and found that
medical error was not included in their guidelines.
“You are obligated to report a physician if you be-
lieve he or she is acting fraudulently – overbilling
and things like that – or is impaired,” Dr. Dossett
said, “but, if he or she made an error, there is no
obligation to report.” 12
Her team is now working on developing guide-
lines to manage interfacility errors. “It’s a complex
problem and I don’t have the answer yet, but I can
tell you that every time I tell people this is what I’m
doing, they launch into a story about a patient they
saw the other week.”
The Role of Health IT
Beyond the mistakes of other providers, the poten-
tial for system failures – especially during the refer-
ral process – concerns Dr. Jacobson. Collecting all
the primary data necessary for making an informed
treatment recommendation can be challenging, and
there is often a lingering worry that an important
piece of clinical information isn’t available at the
consultation.
“When I speak to patients, one of their greatest
fears is that many different specialists are involved
in their care and they aren’t sure, for example, that
the surgeon who told them they need an operation
reached the recommendation based on review of all
the data and input from the whole team,” Dr. Jacob-
son recounted. While he doesn’t doubt that system
failures occur, he said he lacks the information to
speak about that risk with patients because those
data are not collected.
“We have not come up with reliable systems for
communicating key data across institutions, and I
think it’s possible that this can put patients at risk,
either because of inadequate data available to make
the treatment recommendation or inordinate delays
that could adversely affect an outcome,” he said.
Like checklists, electronic health records
(EHRs) were once expected to revolutionize patient
safety by eliminating medication errors and other
communications failings. However, the benefits
seen in earlier studies are not being borne out in
real-world clinical settings.
EHR usability is a major concern for patient
safety, as shown in a recent study conducted in a pe-
diatric patient population. 13 Of 9,000 patient safety
reports from three health-care institutions made
between 2012 and 2017 that were likely related to
EHR use, 36 percent had “usability challenges” that
contributed to a patient safety event, like a system
defaulting to an incorrect date and time for a medi-
cation order, which led to a missed dose. Research-
ers estimated that nearly 19 percent of these might
have resulted in patient harm.
“EHRs in their current iteration, even within an
organization, are inadequate communication tools,”
said Dr. Jacobson.
“EHRs can go either way,” said Lisa Hicks,
MD, MSc, a staff hematologist at St. Michael’s
Hospital and assistant professor at the University of
Toronto and chair of ASH’s Committee on Quality.
“Certainly, for standardization of medical order
entry and drug order entry, we think they improve
patient safety.”
However, she added, “when EHRs are too oner-
ous and create an increasing burden for physicians,
there is a potential for them to increase burnout
and increase the medical error rate.”
Researchers from Pascal Metrics, a patient safety
organization, found that EHRs could be used to
predict patient harm before it happens. 14 They tested a
method of extracting safety indicators from EHRs to
identify harm and its precursors in two large commu-
nity hospitals, finding that the EHR-based analytics
tool detected and predicted harm in real time.
Dr. Jacobson’s dream is a bit simpler. “At the top
of my wish list is a simple, asynchronous, closed-
loop communication system between key providers
who have to weigh in on a therapeutic decision,” he
commented. “In this type of system, I would know
that when I sent Mrs. Jones to Dr. X my question
would be answered, and that Dr. X had access to all
the data that he needed at the time of the consulta-
tion to render an opinion. We could all agree on
the pathology and the imaging and sign off on the
final treatment decision.” Ideally, he added, there
would also be a means of sharing some details of the
process with the patient.
Human Error or System Failure?
The topic of medical error got a big boost in the
popular press with the publication of The Checklist
Manifesto by Atul Gawande, MD, MPH, in 2009.
Dr. Gawande – a surgeon, writer, researcher, and
now CEO of the recently formed health-care ven-
ture from Amazon, Berkshire Hathaway, and JP
Morgan – differentiates two types of errors: errors
of ignorance, or mistakes made because science has
given us only a partial understanding; and errors of
ineptitude, where the knowledge exists but was not
applied appropriately. As science advances, he sug-
gested, the balance has shifted from ignorance to
ineptitude, leaving clinicians with simply too much
to remember.
It is the errors of ineptitude that Dr. Gawande
targeted with checklists – tools long used in the avia-
tion industry (and advocated for in the health-care
industry) to avoid overreliance on memory, improve
team communication, and formalize workflow. The
approach reframes the discussion about medical
mistakes, from one about “bad actors” to one about
how systems can be made safer.
In an expansion of the concept, in 2009, Dr.
Gawande and colleagues tested implementation
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ASH Clinical News
December 2018