At Your Defense: Are Physicians Actually Making More Mistakes?
Fatal medical errors are on the rise, alarmingly so when comparing the latest data with the watershed estimate from the Institute of Medicine that has been used for nearly two decades.
But a 2016 study by Martin Makary, MD, MPH, put the mean rate of deaths from medical error at more than double the IOM’s figure. Dr. Makary estimated that more than 250,000 deaths are now caused by medical error annually. (BMJ 2016;353:i2139.) This number is significantly higher than the IOM’s estimate of 44,000 to 98,000 in its report, “To Err is Human: Building a Safer Health System.” (Washington: National Academies Press; 2000.) But does this mean that physicians have actually made more fatal errors?
This “rise” in medical error may have less to do with an increase in incidence and more to do with growing recognition. Dr. Makary’s analysis estimated medical error to be the third most common cause of death, after only heart disease (614,348) and cancer (591,699) based on the CDC’s number of deaths in 2013. (http://bit.ly/2sHsAd1.) The CDC does not traditionally recognize medical error as a cause of death, but it would likely be underreported if it did. Nevertheless, recognizing that medical error is a substantial cause of mortality brings to light another question: Has medicine done anything to help physicians reduce it?
The Anatomy of Error
Claims of medical negligence are traditionally based on clinician error, which can be broken down into three categories. Claims can be based on allegations of diagnostic error, in which the wrong diagnosis was made or a delay in diagnosis led to patient injury. Treatment errors include medication errors like selecting the wrong intervention or treatment, delay in treatment, or the failure to perform an operation or a procedure successfully. Then there are preventive errors, which result from failure to provide prophylactic treatment, sufficient monitoring, or timely follow-up care.
A malpractice claim is founded on the allegation that a clinician failed to meet the standard of care due to his error in diagnosis, treatment, or opportunity to prevent patient injury. In fact, the story painted by a plaintiff attorney tends to portray an isolated image of a physician generating too narrow of a differential diagnosis or failing to address an abnormal lab value or stabilize an abnormal vital sign promptly. A defense attorney would never point out the three traumas, two septic patients, and one in-house code that the defendant physician also treated because this would garner no sympathy for the defendant.
The other type of error outlined in the 1999 IOM report, system error, was identified as the bigger problem in health care. System error contributes to wrong medication dosing when medicines are available in very high concentrations, wrong diagnostic testing when electronic health record screens display test selections too closely together, and delay in treating emergency medical conditions when specialists are not available.
EHRs are a common source of system error, such as when they prevent physicians from efficiently sharing relevant clinical information, creating unreadable documents and drowning us in a sea of useless data. (Table.)
Causes of Diagnostic Errors
Identifying diagnostic error is only part of the picture when trying to understand malpractice claims. Identifying the primary and contributing factors to diagnostic error brings us closer to understanding how we can prevent them. A 2007 study by Kachalia, et al., revealed that 79 (65%) of the 122 closed malpractice claims were due to missed or delayed ED diagnosis. (Ann Emerg Med 2007;49[2]:196.) The causes of these diagnostic errors were multifactorial, but the most common contributing factors included failure to order appropriate diagnostic tests, inadequate medical history or physical examination, and incorrect interpretation of diagnostic and laboratory tests, such as x-ray (62%), CT (7%), or ECG (10%).
The Kachalia study analyzed the causes of diagnostic errors, and attributed cognitive processes as the most significant contributory factor (96%). A more recent study by the Doctor’s Company cited inadequate patient assessment (52%) as the most common cause of diagnostic error. (http://bit.ly/2sHATFV.) Both studies, however, seem to underestimate the impact of ineffective workflows, cumbersome EHRs, and crowded EDs on cognitive processes. Any practicing EP would agree that our cognitive processes deteriorate at the 11th hour of a shift, after the 25th patient seen, and when we are overwhelmed by frenetic disruptions.
A Two-Pronged Approach
It is clear that we have failed to reach the IOM’s stated goal of achieving a 50 percent reduction in medical error by 2004. If the current estimates are true, we have experienced a fivefold increase in medical error. Clinical decision support has not been the panacea that was hoped for.
What we should hope for in the near future are EHRs with intuitive, user-centered design that bring only the most important clinical information to the clinician, interoperability that allows for seamless information exchange between outpatient and inpatient clinicians, and intelligent clinician decision support that avoids the mindless, irrelevant window pop-ups and alerts us only when we really need alerting.
We physicians can reduce errors in our daily practice by collaborating with our hospital administrators to create the most efficient clinical workflows, establishing evidence-based protocols that still allow for sound clinical judgment and implementing a robust risk management program in emergency medicine.
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