Zero Tolerance for Medical Errors
Imagine a fully-occupied Boeing 747 Jumbo Jet crashing every night and killing all passengers on board.
As horrifying as this sounds, that number is equivalent to the number of deaths caused each day by medical error. What’s even more disappointing about these statistics is that the healthcare industry doesn’t acknowledge that they even exist. The public doesn’t recognize this because we depend on the media to get our information. It would be a headline news story on CNN if an aircraft skidded off the runway, even if there were no casualties because this is news.
The Federal Aviation Administration requires a root cause analysis to be completed on every adverse event, with a review of policies, procedures, and guidelines, as well as modifications to prevent these errors from reoccurring.
Now imagine if the healthcare industry did the same. How many errors could we prevent?
IOM released a report in 1999 that identified medical errors as the third leading cause of death in the United States. This is not a new statistic. The numbers have not changed in 20 years, despite many efforts to improve them.
When a root cause analysis is completed on a medical error, the results are that 80% of these errors occur at the critical decision-making point in the diagnosis. This is a crucial point in the process, as the choice is made to provide the right medication, the right dose, and the right tests to correct the illness. How can we ensure that the right care is provided each time?
We must focus on our current guidelines, procedures, and policies, and modify them in such a way that we can prevent these errors from occurring in the first place. Technology is evolving every day, and electronic medical records should be capable of alerting medical staff when something doesn’t appear accurate. We need to look at the methodology of dispensing medications, as well as minimize human error as much as possible by consistent training on new guidelines and procedures as they change. Most of all, we must conform to a culture of zero tolerance. Bottom line is, in healthcare, 99% isn’t good enough.
The aviation industry has this system figured out. The healthcare industry needs to do the same so that we are not repeating these errors 10 years from now.
Kayur V. Patel, MD, MRO, FACP, FACPE, FACHE, FACEP