Friday, March 25, 2016

Futility Of Eliminating Human Errors In Medicine

Is it possible to eliminate human error in medical care? Is it a sign of mental illness to even think it can be done with absolutely 100% certainty? News out of New Haven, CT demonstrates another horrific error in patient mismanagement. At the Yale New Haven Hospital, a patient had the wrong rib removed from her body. She had a precancerous lesion in her 8th rib but the surgeon resected the 7th rib instead. This despite the fact that the proper rib was previously identified with coils and dye. One has to wonder why mistakes like this still happen when there is a room full of medical professionals who perform a time out prior to incision to make sure the correct patient and procedure is being done, radiographic images available at the touch of a button to correctly identify the side and location of the lesion, and the specimen that was removed with no evidence of the markings that were supposedly in place.

Yet hospital and government administrators continue to add ever more rules to healthcare to try to reach a utopian level of patient safety. Our blood bank requires two blood samples from a patient for a simple type and cross. These samples have to be drawn at least ten minutes apart which means the patient has to be stuck with a needle twice. Years ago only one specimen was necessary. I'm sure somebody received the wrong blood type which resulted in this decree.

Another example of this quixotic pursuit of healthcare perfection is in our heparin dispensation. A few years ago at a local LA hospital, a Hollywood celebrity's twin babies received a massive overdose of heparin. Consequently new rules were established for nurses who dispense heparin to their patients at our facility. It now requires two nurses to read the heparin label before one of them can draw it up and give it to the patient. Obviously having only one nurse carefully read a drug's label before giving it to the patient is not good enough to prevent medication errors.

The latest order to come from the C-Suite regards attempts to eradicate wrong sided surgeries. Previously a surgeon could just make a mark on the patient's correct side. Any mark will do, like an "X". Then the bosses decided that wasn't good enough and the surgeons had to write "Yes". That still wasn't adequate so the surgeons were told they had to initial their mark, because I guess they didn't want just anyone to write "Yes" on the patient. Apparently that still wasn't good enough to defeat wrong sided operations. The latest order is that besides all the previous rules for marking a patient, the surgeon has to write "No" on the side that isn't being operated on. What?

To me that was the most absurd plan yet. Is there any proof that any of these actions have lessened, much less eliminated, wrong sided procedures? Yes medical errors cause a huge amount of unnecessary suffering. But try as the administrators might, they need to realize that humans make errors. We have human patients being ministered by human care givers covering thousands of cases per year. No matter how many rules are devised to prevent mistakes, it will still happen. Before long, your loved ones coming out of an operation will be covered in more ink than you'll see at a Hell's Angels national meeting. Adding more decrees to the already extensive preoperative preparation is unlikely to significantly make a dent in the number of errors that are made. But at least the hospital can say they are doing everything imaginable they can to eliminate it.

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