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Medical Errors
12 Plays2 years ago
In this episode of Critical Matters, Dr. Zanotti is joined by Dr. Nitin Puri. As a critical care physician, Dr. Puri is the Division Head for Critical Care Medicine, and Co-Director for the Center for Critical Care Medicine at Cooper University Health System. He is an Associate Professor of Medicine at Cooper Medical School of Rowan University, in Camden, New Jersey. Together, they discuss medical errors in healthcare.
Additional Resources:
“To Err is Human: Building a Safer Health System.” The landmark publication y the Institute of Medicine highlighting medical errors as a critical cause of deaths in the US healthcare system: https://www.ncbi.nlm.nih.gov/pubmed/25077248
Medical error – the third leading cause of death in the US: https://www.ncbi.nlm.nih.gov/pubmed/27143499
The Safety of Inpatient Health Care. New England Journal of Medicine 2023; https://www.nejm.org/doi/full/10.1056/NEJMsa2206117
The Communication and Optimal Resolution (CANDOR) toolkit from the Agency for Healthcare Research and Quality (AHRQ). CANDOR is a process that health care institutions and providers can use to respond in a timely, thorough and fair way when medical errors occur and cause patient’s harm: https://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/candor/introduction.html
A powerful video on to topic of disclosure of medical errors. Worth a view: https://www.youtube.com/watch?time_continue=4&v=xeMWizTodYw
Books Mentioned in this Episode:
The Fearless Organization: Creating Psychological Safety in the Workplace for Learning, Innovation, and Growth. By Amy Edmondson: https://bit.ly/3OQe1zV
Pachinko. By Min Lee Jee: https://bit.ly/3DNJegK
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Transcript
Introduction to the Podcast
00:00:06
Speaker
Welcome to Critical Matters, a sound podcast covering a broad range of topics related to the practice of intensive care medicine.
00:00:14
Speaker
Sound provides comprehensive critical care programs to hospitals across the country.
00:00:19
Speaker
To learn more about our programs and career opportunities, visit www.soundphysicians.com.
00:00:26
Speaker
And now, your host, Dr. Sergio Zanotti.
Impact of Medical Errors
00:00:35
Speaker
It has been almost 25 years since the publication of the Institute of Medicine report entitled To Error is Human, Building a Safer Health System.
00:00:44
Speaker
This landmark report stated that medical errors cause between 44,000 and 98,000 deaths every year in American hospitals, and over 1 million injuries to patients.
00:00:54
Speaker
This publication marked an inflection point in the recognition of the perils and prevalence of medical errors in hospitals.
00:01:01
Speaker
In today's episode of the podcast, we will discuss medical errors.
Current Status and Efforts in Patient Safety
00:01:04
Speaker
Where do we stand today and what can we do to continue to make care for our patients safer?
Meet Dr. Nitin Puri
00:01:10
Speaker
Our guest is Dr. Nitin Puri.
00:01:12
Speaker
Dr. Puri is a critical care physician.
00:01:14
Speaker
He's a division head for critical care medicine and the co-director for the Center for Critical Care Medicine at Cooper University Health System in Camden, New Jersey.
00:01:22
Speaker
He's an associate professor of medicine at Cooper Medical School of Rowan University.
00:01:27
Speaker
Dr. Puri is a recognized clinician, educator, and researcher with a special interest in medical education, medical errors, point of care ultrasound, and mechanical support.
00:01:36
Speaker
Nitin, welcome back to the podcast.
00:01:39
Speaker
Sergio, thank you for inviting me back.
00:01:43
Speaker
Well, we had a conversation on the same topic almost five years ago as we were talking.
00:01:49
Speaker
A lot has happened since.
00:01:51
Speaker
But I think a good place to start would be if you could tell us why do you think this is an important topic for clinicians at the bedside?
00:01:59
Speaker
Well, I think all of us make errors.
00:02:03
Speaker
And how do we deal with them?
00:02:06
Speaker
psychologically and how do we, how do our patients handle it and how can we help our patients get through that process and help ourselves get through that process.
00:02:23
Speaker
One of the things that I always appreciate, Nitin, is that the sign of intelligence really is our ability to change our mind and to learn new things, right?
COVID-19 and Exacerbation of Medical Errors
00:02:33
Speaker
And we talked about this back in 2018.
00:02:36
Speaker
So my next question is, since we last talked about medical errors, what is one thing that you have changed your mind about or learned about this topic?
00:02:45
Speaker
Yeah, that's a great question.
00:02:48
Speaker
So since the last time we spoke, there was a global pandemic.
00:02:53
Speaker
And, you know, fear and panic had gripped our subspecialty pretty substantially.
00:03:02
Speaker
And that definitely led to errors.
00:03:04
Speaker
And it also made me think and reflect at that time, what can I do as a bedside clinician to create an environment where we can talk about those errors openly and
00:03:23
Speaker
And it was actually a book you had recommended to me, the Amy Edmondson's book.
00:03:31
Speaker
I know she's been a guest on your podcast.
The Role of Psychological Safety in Healthcare
00:03:35
Speaker
And, you know, I think creating psychological safety in the critical care environment is one of the fundamental tenets of what we do to recognize that failure is common and
00:03:49
Speaker
And how we respond to it is more important than failure occurring.
00:03:54
Speaker
Perfect.
00:03:54
Speaker
And I do believe it.
00:03:55
Speaker
We'll talk a little bit about it.
00:03:57
Speaker
that psychological safety is a concept that obviously not only applies to dealing with failure and medical errors, but also applies to being a high-performing ICU.
00:04:09
Speaker
And I would also say that between 2018 and today, that is a word that has become a much more frequent part of my lexicon than it was before.
00:04:17
Speaker
As some people who might be listening know, I was your fellowship program director many, many years ago.
00:04:24
Speaker
And I don't think that I ever mentioned that word during your critical care and pulmonary fellowship training at all.
00:04:32
Speaker
Yeah, no, no, no.
00:04:33
Speaker
I actually don't remember seeing you much during my training.
00:04:37
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Well, that's an indictment on you.
00:04:38
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I was always there.
00:04:43
Speaker
So as we move along with the topic, I think it's always good to start by aligning expectations and making sure everybody's on the same page.
00:04:54
Speaker
So why don't we start with some definitions?
00:04:56
Speaker
I think a lot of times people are talking about different things, but using the same terminology, maybe with a different fully understanding.
Understanding Medical Errors
00:05:08
Speaker
So what is a medical error?
00:05:11
Speaker
Yeah, that is, I think, definitely most important.
00:05:15
Speaker
You know, defining what is happening is very, very important.
00:05:19
Speaker
So a medical error is any error that occurs in the delivery of medical care, whether harmful or trivial.
00:05:29
Speaker
And I think it's worth pausing there and emphasizing that a medical error does not require...
00:05:41
Speaker
to cause harm to be considered a medical error, correct?
00:05:47
Speaker
Yeah, that is correct.
00:05:49
Speaker
And I think that that's very important because there are further definitions, which, you know, I think we'll talk about.
00:06:00
Speaker
And, you know, medical errors that cause harm, you know, go into the next category, serious medical error.
00:06:05
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So that's a medical error that causes harm.
00:06:09
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or it has substantial potential to cause harm.
00:06:14
Speaker
And that's very different than a medical error.
00:06:17
Speaker
But addressing errors, thinking about them, reflecting upon them, hopefully will prevent a serious medical error.
00:06:28
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Correct.
00:06:28
Speaker
And I think that's what I was trying to also articulate is that when we think of medical errors, we should really be focused on process of delivery of care.
00:06:37
Speaker
as opposed to the outcome.
00:06:39
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And I think this is true for so many decision making approaches is that we think of the outcome too much, but outcomes are important obviously, but ultimately the only way we can learn is by focusing on the process.
00:06:54
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Because if I'm lucky, I might have a good outcome or I might follow the right process and have a bad outcome for other reasons.
00:07:03
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And I wouldn't be able to learn if I wasn't focusing on was the process done correctly.
00:07:09
Speaker
Yeah, I think that that's actually really interesting because one of the.
00:07:16
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medical errors since the errors human report came out in 2001 that's improved substantially in the United States is the decrease in stints of hospital acquired infections.
00:07:29
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And there's two pathways that are going in hospital acquired infections in the field of critical care.
00:07:37
Speaker
One pathway is we focus on
00:07:43
Speaker
having a quality process to prevent hospital-acquired infections.
00:07:46
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And if we do have hospital-acquired infections, we try to understand why they occurred and, you know, think about them.
00:07:54
Speaker
And another pathway is, it's even led to, you know, definition changes, you know, for ventilators.
00:08:03
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Pneumonia is gaining the system or, you know, drawing less cultures.
00:08:09
Speaker
And, you know,
00:08:10
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That is the wrong way to address an error or a problem.
00:08:18
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What you want to do is improve the quality of the system, even if you go through
00:08:23
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a tough moment because that will produce the quality outcomes and that's the type of place you want to be delivering care.
00:08:30
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Absolutely.
00:08:31
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So I think it's really about focusing on how do we improve our process in order to be more likely to deliver safe care.
00:08:39
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So the next definition I think that often is thrown around or category is an adverse event.
Adverse Events: Preventable vs Non-Preventable
00:08:47
Speaker
How would you define that?
00:08:50
Speaker
Yeah, so adverse events...
00:08:53
Speaker
is any injury that occurs due to medical management, and it can be broken up into a non-preventable adverse event or a preventable adverse event.
00:09:05
Speaker
And a non-preventable adverse event is caused by medical care without any apparent error.
00:09:12
Speaker
So an example would be somebody is on a heparin drip, they're anticoagulated for whatever reason, and then they have an intracranial hemorrhage.
00:09:23
Speaker
You know, if they were supposed to be on the apron drip, the dosing was correct.
00:09:29
Speaker
At least to our knowledge, it's unclear to us why the bleed occurred.
00:09:34
Speaker
That would be a non-preventable adverse event.
00:09:42
Speaker
Well, a preventable adverse event would be, you know, the bolus was too high and that caused the bleed or the dosing was too high and that caused the bleed.
00:09:54
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I think it's important because there obviously are known risks with many of the treatments that we implement in the ICU.
00:10:01
Speaker
And people have multiple comorbidities.
00:10:06
Speaker
And every treatment has a risk, right?
00:10:08
Speaker
And sometimes these are non-preventable.
00:10:10
Speaker
And understanding that and understanding that maybe the process was the right process in that patient is important because if we were to change it just for the outcome, we could actually put more patients at danger.
00:10:22
Speaker
Now, we talked about the relationship of process to outcome and how sometimes you might have no harm in the patient, but it's still a medical error.
00:10:31
Speaker
What's a near miss?
00:10:34
Speaker
Yeah, so a near miss is an error in care that has substantial potential to cause harm, but does not.
The Importance of Near Misses
00:10:46
Speaker
either because it's intercepted or because it unexpectedly causes no harm despite reaching the patient.
00:10:54
Speaker
So a near miss is luck.
00:10:58
Speaker
And luck cannot be your strategy.
00:11:01
Speaker
And those should be treated as sentinel events and dissected and understanding the root cause of why they occurred to try to prevent something like that occurring again.
00:11:17
Speaker
And I guess in some circumstances, a good process could create a near miss if you intercept it before it reaches the patient.
00:11:25
Speaker
Is that correct?
00:11:27
Speaker
That is correct.
00:11:29
Speaker
A good process would allow you to catch.
00:11:37
Speaker
Now, it wouldn't necessarily, hopefully it's not a near miss to get that close, but, you know, let's say, you know,
00:11:45
Speaker
At our facility or our colleagues, before we do a procedure, we call a timeout.
00:11:51
Speaker
So it's clear to us that when we're putting a central line, we're putting it on the side we want to, and we've consented the patient's family.
00:12:02
Speaker
So we're not getting ourselves into a situation where, you know, the horrific stories of doing surgery on the wrong of the limb or something like that.
00:12:11
Speaker
Perfect.
00:12:12
Speaker
So now that we've defined some of the key elements of what a medical error is, what's in your midst, what's preventable, what's not preventable, let's talk a little bit about the scope of the problem, Nitin.
00:12:24
Speaker
And I did mention in the intro the Institute of Medicine to Error's Human Report, which was based on one of the landmark original studies on medical errors, which was the Harvard Medical Practice Study.
00:12:39
Speaker
They quoted...
00:12:42
Speaker
up to maybe 100,000 deaths in hospitals and a million injuries back 25 years ago.
00:12:50
Speaker
What do we know today?
00:12:52
Speaker
Is our medical errors a leading cause of death?
00:12:55
Speaker
What does the recent literature suggest in terms of what has happened or not happened over the last 25 years?
00:13:03
Speaker
Yeah, I think it's important to digest the literature and understand that
00:13:14
Speaker
medical errors and how we understand the magnitude of them is epidemiological based work.
00:13:22
Speaker
So you go back and analyze records and then you extrapolate going forward.
00:13:32
Speaker
There was a very...
00:13:35
Speaker
controversial, but also thoughtful piece that was put out that looked analyzed records from North Carolina in 2013, and I think the study came out in 2017, that said approximately 250,000 people died of medical errors in the United States.
00:13:57
Speaker
every year that would have put medical errors as the third leading cause of death in the United States.
00:14:04
Speaker
And then the study went on to say, which is important, but as a clinician who does fill out death certificates, they say, and likely the number's even higher than that because medical error is not even put on death certificates where we can directly attribute death or harm due to a medical error.
00:14:25
Speaker
So I guess what I would say is that the –
00:14:31
Speaker
The magnitude of the problem is difficult to quantify, but if you were to look granular at studies that have come out since the Harvard Medical Practice Study in the early 90s, including more studies by that same group at other places like in Utah and Colorado, there are a lot of medical errors which occur, and there is significant potential for harm, and I think anyone who practices knows it's an issue.
00:15:00
Speaker
And that we still have a tremendous, we still have a lot of opportunity to improve our care.
00:15:08
Speaker
And I think an important point, like you mentioned in the study that I think was in BMJ by Macri that reported it might be the third cause of death in the United States, that every report that's been published recognizes that because of limitations due to the methodology, we're probably not
00:15:29
Speaker
undercounting medical serious medical errors.
00:15:31
Speaker
Furthermore, a lot of medical errors are recognized because people report them.
00:15:36
Speaker
And we know that reporting is also something that probably could be a lot better.
00:15:40
Speaker
And we'll talk about that a little bit later.
00:15:42
Speaker
So in summary, it really seems like it is a real problem.
00:15:46
Speaker
And like you said, it happens probably every day in hospitals around the country, right?
00:15:53
Speaker
Yeah, I mean, I don't think we can even say every day.
00:15:56
Speaker
I think, you know,
00:15:59
Speaker
I think a good article to talk about would be that recent New England Journal of Medicine article.
00:16:03
Speaker
It's, I mean, one out of four admissions seems a pretty reasonable number to cite for medical errors.
00:16:13
Speaker
And you want to mention a little bit about, so this was recently re-evaluated, and we'll link all these articles in the show notes in a study that was, I think the
Medical Errors as a Leading Cause of Death
00:16:23
Speaker
original group was also from the
00:16:26
Speaker
from, from Harvard and the medical practice study to kind of a continuation, any, any comments from what we learned from that, the safety of inpatient healthcare?
00:16:35
Speaker
Yeah.
00:16:36
Speaker
So that's a really important study.
00:16:38
Speaker
Um, and although it's not specifically focused on critical care medicine, it is inpatient practice.
00:16:46
Speaker
And, um,
00:16:48
Speaker
You know, one out of four patients had medical errors.
00:16:53
Speaker
It was seven hospitals of varying sizes.
00:16:56
Speaker
Actually, if I'm not right, maybe it was 11 hospitals of varying sizes.
00:17:00
Speaker
And I think two hospitals greater than 700 beds all the way down to hospitals less than 200 beds.
00:17:07
Speaker
And I think they sampled something like 2,800 records, nine nurses reviewing the records, then adjudicated by eight physicians.
00:17:17
Speaker
This group has been doing this methodology for now, you know, 20, 30 years.
00:17:23
Speaker
So I think they have a very clean way of looking at medical errors, and they're continuing trying to refine it.
00:17:30
Speaker
And, you know, 7% of errors with serious errors
00:17:35
Speaker
harm and 0.2% leading to, I think, death.
00:17:43
Speaker
So 0.2% of 2,800 is not a significant number, but if you think about the number of people who are hospitalized in the United States, then that number starts to grow substantially of the number of people who've possibly been harmed.
00:18:00
Speaker
So that study was very, very insightful and well done.
00:18:05
Speaker
And the other thing I recall that I think is important for our discussion today as well is that you mentioned that one in four patients, so 25% of admissions, are associated with a medical error during their hospital stay.
00:18:20
Speaker
And of those, again, one out of four of those errors or 25% of those were preventable.
00:18:26
Speaker
So that's really, I think, where we should really focus on as clinicians is, okay, let's make sure that we...
00:18:34
Speaker
do everything we can to avoid preventable errors, right?
00:18:38
Speaker
And then we can try to figure out, okay, what else can we do to improve the delivery of care to prevent adverse events and other things or minimize them?
00:18:50
Speaker
100%.
00:18:50
Speaker
I think that there are some simple strategies to address preventable errors.
00:18:57
Speaker
And one of the simplest is communication, clear, direct communication, making sure that those you're communicating with understand what you're saying.
00:19:13
Speaker
You can follow through on their plan and they can follow through on your plan to care for patients.
00:19:19
Speaker
That goes along with a clean and effective sign out and a multitude of things.
00:19:27
Speaker
So before we dive into more interventions that we could do to move the needle in the right direction, let's dissect a little bit more the types of failure and the most common types of medical errors that we see in the hospital.
00:19:41
Speaker
I believe, Nitin, that unfortunately critical care and medicine in general
00:19:47
Speaker
have a very bad relationship with failure, right?
00:19:50
Speaker
We have been brought up and educated and really just judging failure is always bad.
00:19:58
Speaker
And it's led to, I think, a lot of blame throughout health care.
00:20:05
Speaker
which is not a very effective way of creating psychological safety or of learning.
00:20:10
Speaker
But the reality is when you really look at failure, there's a lot to be learned from failure.
00:20:16
Speaker
Not all failures are bad and not all failures are blameworthy.
00:20:20
Speaker
So when you think of failures of mistake, how would you classify them?
00:20:26
Speaker
Yeah, that's a good point.
Classification of Failures in Healthcare
00:20:30
Speaker
So, you know, I think there's three ways that I like the way Amy Edmondson had quantified them.
00:20:39
Speaker
I described them preventable, complex, and intelligent.
00:20:45
Speaker
Preventable error is a deviation from a process.
00:20:48
Speaker
You know, I decided, you know,
00:20:52
Speaker
I trained in the era of using ultrasound to place a central line.
00:20:57
Speaker
I have now decided to put the central line without the ultrasound because, you know, I didn't want to wait.
00:21:06
Speaker
And so I placed the line and I caused a pneumothorax.
00:21:09
Speaker
That was a deviation of practice.
00:21:11
Speaker
And that's a preventable error.
00:21:14
Speaker
A complex error is a system failure.
00:21:19
Speaker
I think a common and important complex error is the workaround, which is, you know, I go to pull Versed because a patient needs a
00:21:37
Speaker
an MRI and they have anxiety.
00:21:40
Speaker
And when I go to pull Versed, I instead pulled Vecaronium.
00:21:44
Speaker
And that's a pretty important case that happened in the past year with a nurse in
00:21:52
Speaker
Tennessee.
00:21:53
Speaker
And the reason that she was pulling medications like that without safety checks was it was a workaround.
00:22:00
Speaker
The medication dispensary machine was not working appropriately for the care that needed to be provided.
00:22:09
Speaker
And so everyone knew that you just bypass the safety system and that had become a normal workaround.
00:22:17
Speaker
So that is a system failure.
00:22:21
Speaker
And then intelligent failure is the failure that we, I think the researcher themselves may be a bit frustrated with, but I think we celebrate a medicine.
00:22:30
Speaker
And it's also, you know, a bit of frustration in medicine that negative trials aren't published, but that's when a clinical trial is negative, but it provides insight into what
00:22:39
Speaker
You know, medications that are being used and why they're being used.
00:22:43
Speaker
And, you know, we had a lot of success with that with COVID, the adaptive clinical trials, you know, saying, OK, no, Plavik doesn't work for a COVID patient, but, you know, modern anticoagulation works for patients not in the ICU.
00:22:55
Speaker
And those were adaptive clinical trials and help inform our practice and help people along the way.
00:23:01
Speaker
I think it's important to emphasize this because we can't always categorize failure as a bad thing.
00:23:08
Speaker
I believe that we should definitely try to prevent preventable failures, right?
00:23:15
Speaker
Like if we have a protocol, we should follow the protocol.
00:23:18
Speaker
There's a reason for that.
00:23:19
Speaker
And deviations from that,
00:23:21
Speaker
require accountability.
00:23:23
Speaker
And those would be the ones that are maybe blameworthy, because I think it's also important to investigate why was the protocol broken?
00:23:31
Speaker
And there's a lot of other reasons that we may talk later.
00:23:34
Speaker
Complex, I think you talked about the workaround, but also in our world, complex failures can also relate to just the severity of
00:23:43
Speaker
interactions between organ failures and the therapies we're doing and the complexity of critical illness and multi-organ failure.
00:23:51
Speaker
And perhaps despite everything that we do, the patient dies and that's seen as a failure, but it was really due to the complexity of the situation or the system.
00:24:01
Speaker
And with intelligent failure, I think that another example that comes to mind that I think is very important that goes outside the context of clinical trials is when we are trying to improve delivery of care and we do a small pilot, right?
00:24:15
Speaker
We say, well, maybe if we did things this way, it would be better.
00:24:19
Speaker
We do a pilot and we realize that, no, actually things are worse.
00:24:22
Speaker
And we stopped there before we have made a big change for everybody.
00:24:25
Speaker
Right.
00:24:26
Speaker
And that is also, I think, an intelligent failure.
00:24:29
Speaker
And those should be celebrated.
00:24:31
Speaker
I agree with you, Nitin.
00:24:32
Speaker
I think they should be celebrated because they are giving us insight into improving care.
00:24:38
Speaker
And I think we need more of that, obviously, at the bedside and in the ICU.
00:24:43
Speaker
Now, the next thing I wanted to ask you about, Nitin, was the types of medical errors that are commonly described or the most common medical errors that we see in the hospital setting.
Common Types of Medical Errors
00:24:56
Speaker
Yeah, almost uniformly in most studies, medication errors are the first medical error that is cited.
00:25:07
Speaker
You know, delivery of medication, wrong dose, wrong patient.
00:25:15
Speaker
And so medication error, and now with medication shortages, it's become even more complex.
00:25:22
Speaker
Yeah.
00:25:24
Speaker
So medication errors really are as number one.
00:25:29
Speaker
Then after that, procedural, surgery procedural related errors.
00:25:34
Speaker
Although there's been some disagreement about that.
00:25:37
Speaker
You know, I think...
00:25:38
Speaker
around surgery itself, perioperative during the surgery, post-surgery, but some of the conversation has not necessarily been during the surgical event, but post-surgical and therapy that's being provided has not been what is advised.
00:25:56
Speaker
And then...
00:25:58
Speaker
You know, patient care errors, you know, something we, I think, as intensivists many times are at the bedside and we're familiar with, whether it's diagnostic, you know, not basically recognizing clinically deterioration and what needs to happen and intervene.
00:26:20
Speaker
And then, you know, the classic hospital-acquired infection would be...
00:26:28
Speaker
Something that is actually easily quantifiable, and a lot of work has gone on to that since Terris Human came out in 2001, and there's been substantial improvement in that realm.
00:26:41
Speaker
I think mainly because it's been able to be quantified and attacked.
00:26:46
Speaker
And I guess another category that maybe not in our world, but in our ED colleagues world is very important is diagnostic errors, right?
00:26:53
Speaker
Where somebody comes in with a bad headache, they do a CAT scan, it's negative, but they didn't narrow it to the LP and then they have a massive secondary subacnoid bleed or something along those lines, or somebody gets sent home with chest pain and they actually had an acute MI.
00:27:08
Speaker
So these are all, I think, like you said, important errors.
00:27:11
Speaker
Now,
00:27:12
Speaker
One of the things that I understand, and I want to hear your comments, is you did mention that with hospital-acquired infections, just the fact that we talk about it all the time, I think, has made us much more aware, and it's been demonstrated.
00:27:24
Speaker
I mean, obviously, Peter Pronovost and others have done, I mean, landmark work on demonstrating that abiding to a process that is evidence-based can decrease the incidence of infections dramatically, right?
00:27:35
Speaker
So...
00:27:36
Speaker
There are processes in place.
00:27:38
Speaker
Some of these may have been abandoned or worked around during COVID, but there's a lot of opportunity to bring those back.
00:27:45
Speaker
But the other thing that I wanted to ask you about is we always complain about the EMR.
00:27:53
Speaker
Yet my understanding, Nitin, is that the literature is clear.
00:27:57
Speaker
Computer physician order entry, which is part of the EMR, and EMR in general have improved health.
00:28:04
Speaker
safety for patients and have decreased errors dramatically.
00:28:08
Speaker
Is that the way you read the literature as well?
00:28:11
Speaker
Yeah, that's actually, if you think about the original Harvard medical practice study, there's been substantial improvement
00:28:20
Speaker
in care delivery and electronic medical records have played a role in that.
00:28:25
Speaker
There are, you know, have been unintended consequences, you know, the copy and paste function.
00:28:31
Speaker
And I think that leads to a different type of medical error.
00:28:34
Speaker
And that was probably different from what we saw in the pre-EMR.
00:28:40
Speaker
But EMR has definitely improved care delivery.
00:28:45
Speaker
And I don't think...
Causes of Medical Errors
00:28:50
Speaker
be curious to see if anyone had other thoughts on that.
00:28:55
Speaker
Perfect.
00:28:56
Speaker
Now, what are some of the common causes of medical errors?
00:29:00
Speaker
Now, we talked about, before we started recording, obviously, that we're going to try to focus on what individual clinicians can do and talk a little bit about system solutions.
00:29:09
Speaker
But when people have looked at medical errors in general, there seems to be some themes that are recurrent.
00:29:17
Speaker
Could you talk about some of those common causes?
00:29:21
Speaker
Yeah, you know, I definitely hit on the first one is communication.
00:29:28
Speaker
So I think that clear and direct communication is really a huge important point in medicine.
00:29:39
Speaker
And we don't, unfortunately,
00:29:43
Speaker
spend enough time, I think, teaching that at the bedside when people are coming up.
00:29:51
Speaker
So I really emphasize that.
00:29:54
Speaker
And then communication between yourself and the nursing staff, yourself and your colleagues.
00:29:58
Speaker
So I think that that's definitely a big one.
00:30:02
Speaker
But that's not the only one.
00:30:05
Speaker
There are definitely a lot of concerns about inadequate information that flows between people.
00:30:13
Speaker
There's
00:30:14
Speaker
You know, patient-related issues is like, you know, you don't have appropriate identification, you don't get consent, you know.
00:30:21
Speaker
And, you know, something that comes up all the time in our world, and especially during COVID, is, you know, are we appropriately staffed?
00:30:27
Speaker
You know, we see appropriate staffing ratios, people, you know, care has improved.
00:30:32
Speaker
But that's not most of the time what I've seen as the...
00:30:41
Speaker
as the cause.
00:30:42
Speaker
And then technical failures, which are common.
00:30:45
Speaker
We use a lot of technology in our world and have devices failed and how do we handle those devices.
00:30:54
Speaker
but I think, again, I keep on going back to communication because I think communication goes back to inadequate information flow.
00:31:02
Speaker
Um, and so I'm very particular about picking up the phone and speaking to people and making sure that I understand what they are saying and that they understand what I'm thinking.
00:31:12
Speaker
And, um,
00:31:13
Speaker
And even if there's a moment of frustration, I try to, because I recognize that'll hamper the flow of information, try to make sure that the patient's at the center of the conversation and that the frustrations can be dealt with later.
00:31:30
Speaker
And I think with regards to communication, one of my favorite quotes, I think it's from Bernard Shaw, is that the biggest problem with communication is the illusion that it has occurred, right?
00:31:40
Speaker
And a lot of times people only measure the effectiveness of their communication based on what they said.
00:31:48
Speaker
And if it wasn't understood, like you said, or if it was misunderstood, it definitely will lead to an error.
00:31:56
Speaker
So making sure that we're verifying, that we're providing the right information, but they're also verifying that there's clear understanding of what we're trying to communicate.
00:32:05
Speaker
And it's very interesting that a lot of the things that you mentioned, Nitin, have all been addressed.
00:32:10
Speaker
And I wouldn't say solved, but they have all been addressed and worked upon by people
00:32:16
Speaker
aviation, right?
00:32:17
Speaker
So, communication through checklist and for process procedures that make sure that everybody's clear, technology failures and redundant systems.
00:32:29
Speaker
These are all things that adequate hours of work and staffing.
00:32:34
Speaker
There's all things that our aviation partners have been working on for many years and that I believe there's still opportunity for us to do a little bit better.
00:32:46
Speaker
Yeah, no, no, I agree 100%.
00:32:49
Speaker
And I think that we, you know, patients are very complex.
00:32:55
Speaker
There's a multiple patients that we're taking care of.
00:32:59
Speaker
And, you know, has information been adequately given to us to be able to care for the patients?
00:33:08
Speaker
And are we in the psychological space to receive that information and, um, move on it going forward?
00:33:14
Speaker
And that's the utility of the checklist.
00:33:16
Speaker
Some very, very important things are, um, you know, moved out of the way.
00:33:23
Speaker
And so you can focus on, uh, you know, perhaps a new problem at hand.
00:33:28
Speaker
I, uh, have a lot of respect for, uh, the safety that's gone on in the aviation industry and, um,
00:33:36
Speaker
I also think that other professions where you have to make split-second decisions, whether it's firefighters or the police, and then having to look back on that, decisions can be very difficult and brutal.
00:33:55
Speaker
And I think that we fall into that category at times.
00:33:59
Speaker
Now, I have to ask you before we move on as a cause of medical errors, because it's something that especially post-COVID, but even pre-COVID has been a topic that is prevalent in health care and in critical care.
00:34:14
Speaker
Does burnout lead to increased medical errors?
00:34:18
Speaker
Yeah, that's a great, great question.
00:34:20
Speaker
Burnout is such a vague topic.
00:34:23
Speaker
Yeah.
00:34:25
Speaker
And it's a catch-all phrase that it's hard for me to directly attribute it to it.
00:34:33
Speaker
What I can tell you is if you've made a medical error, that will lead you to burning out.
00:34:41
Speaker
I think the causation, that's pretty clean.
00:34:44
Speaker
That'll lead to that.
00:34:45
Speaker
But as somebody who is, you know, burnout leads you to being disengaged,
00:34:52
Speaker
And then that, you know, you will definitely have more of a chance of creating medical error.
00:34:57
Speaker
If you work in a space that doesn't have psychological safety and that makes you burn out, that will lead to medical error.
00:35:06
Speaker
But burnout itself, I have not seen anything directly.
00:35:14
Speaker
Well, I think that's a perfect lead way to our next topic, which is really how does the individual clinician listening to us understand?
00:35:27
Speaker
improve their role in making care safer.
00:35:31
Speaker
And before we go into what people should do, since you mentioned it, maybe we should talk first about the effects on the clinician who made the error, right?
00:35:41
Speaker
So we always obviously are very concerned with when we have a severe medical error, a serious medical error on the implication it has on the patient and their family.
00:35:52
Speaker
but there's also something described as second victims.
00:35:55
Speaker
Can you talk a little bit about that, Nitin?
00:35:59
Speaker
Yeah.
Clinicians as 'Second Victims'
00:36:01
Speaker
This is a really important and big topic for us as intensivists.
00:36:12
Speaker
You know, when you make an error, you know, you need to disclose to the family and, you know,
00:36:21
Speaker
being supported to be able to disclose and be in a supportive environment is very important too but even after you're disclosed you yourself feel awful and you may be beating yourself up and really taking a lot of uh you know psychological blows that may be internal or from others people whispering in the hallways like oh yeah do you see what happened to him you know or and
00:36:46
Speaker
it's very very important to recognize there is a second victim when a medical error occurs you know something uh possibly bad may have happened to a patient or but there's also another human on the back side who committed the error and you know most physicians or most healthcare practitioners got into this to care for others and be you know look out for others and when you've caused
00:37:10
Speaker
harm or inadvertent harm to somebody, the toll on you can be tremendous.
00:37:14
Speaker
So that's, you know, the second victim.
00:37:16
Speaker
And, you know, to link back into the burnout, you know, that, if you are not able to engage that moment as a colleague or as a clinician in a manner where you can, I don't know if you'll ever be able to make it something positive, but make it a moment of growth and resilience because, you know,
00:37:39
Speaker
You were trying the best you could.
00:37:41
Speaker
You were being thoughtful.
00:37:43
Speaker
You made a mistake or the system was inappropriate.
00:37:47
Speaker
Then that will lead people to not want to practice medicine, not just critical care.
00:37:54
Speaker
For sure.
00:37:56
Speaker
And I think, Nathan, like you mentioned, right, recognizing also the impact it has on the individual clinician should make us more empathetic towards our colleagues and to be more supportive and less blaming and more asking how we can improve the system and understand what really happened.
00:38:14
Speaker
And one of the topics you mentioned at the beginning, the case of the nurse in Tennessee, and I think that, correct me if I'm wrong, but that went to, I think, a criminal court and obviously resulted in, I think, a significant harm on the nurse, but
00:38:36
Speaker
except for people who do it, I mean, with a criminal intent, I don't think any healthcare worker goes to the hospital thinking that they want to harm another patient, right?
00:38:46
Speaker
That's not what we went into healthcare.
00:38:47
Speaker
So I think that maybe depenalizing some of these medical errors and really trying to find ways of improving the system and giving people the tools and knowledge that they need to provide the best possible care is really the way to go.
00:39:02
Speaker
So what would you recommend,
00:39:05
Speaker
for the individual clinician as step one in improving patient safety and how we deal with medical errors?
00:39:16
Speaker
It's funny, but to err is human, right?
00:39:18
Speaker
That's the 2001 report.
00:39:21
Speaker
We all make mistakes.
00:39:23
Speaker
We make them every day.
00:39:25
Speaker
And to embrace that an error is the starting point
00:39:32
Speaker
in a conversation, not the end of a conversation, and to expand, you know, to dissect that error, open it up, and be allowed to think about it and see why it occurred is very, very important.
00:39:50
Speaker
So the individual clinician, if I was to make one point, I would say is that be kind to yourself, that voice in your head.
00:40:00
Speaker
Don't be angry with yourself.
00:40:04
Speaker
And if you have a colleague who makes an error, be empathetic because the next time it could be you and be supportive.
00:40:13
Speaker
And, you know, with the family, sometimes the families are very, very angry at times.
00:40:18
Speaker
They're going to be angry.
00:40:19
Speaker
This is their loved one.
00:40:20
Speaker
You know, we're happy.
00:40:22
Speaker
You know, we're a very specialized group of medicine and expect us to be perfect.
00:40:28
Speaker
You know, the patients are so sick, so if an error is made, it could be catastrophic.
00:40:31
Speaker
If it's a small one, but allowing them to have the space to be frustrated and being able to put it in context is important.
00:40:40
Speaker
So resilience is what I would say is understand everything.
00:40:47
Speaker
how to build resilience in your own life and, um, what is it that, um, you need to, uh, build up that, uh, so you have that psychological, uh, uh, ability to handle mistakes.
Disclosing Errors to Families
00:41:02
Speaker
And what about, um, you did mention the families and, uh, any suggestions, uh, or tips on how to best disclose medical errors to patients and families?
00:41:16
Speaker
Yeah.
00:41:16
Speaker
Um,
00:41:18
Speaker
I definitely have a couple of suggestions.
00:41:20
Speaker
So I think that after error has been made, it's important to try to deal with the outcomes of the error.
00:41:30
Speaker
And medically, if you are not in the psychological space to be able to do that, if you have a colleague or somebody who can help you out in that moment, lean on them and be transparent with them.
00:41:41
Speaker
Say, listen, I'm just not, I don't have the headspace right now to deal with this.
00:41:45
Speaker
And I just need to take a break.
00:41:47
Speaker
You know, the ability to express yourself open and honest to another colleague so the patient can still receive care.
00:41:55
Speaker
But, you know, after that point is,
00:41:59
Speaker
being honest with the families without self-flagellation.
00:42:02
Speaker
There, for good reason, is some historical distrust of medical providers in this country.
00:42:11
Speaker
So I try to be as transparent as possible.
00:42:15
Speaker
But I think when I was a younger clinician, I would just be like, I did it.
00:42:20
Speaker
I made a horrible mistake.
00:42:21
Speaker
I'm sorry, I'm sorry, I'm sorry.
00:42:23
Speaker
And that's okay, but that's you...
00:42:28
Speaker
venting to the family or You know looking for the family to comfort you in a dark moment and that that's what you know don't need to do you need to Be professional and say listen.
00:42:41
Speaker
I made a mistake and
00:42:43
Speaker
or a mistake was made that possibly led to harm or did lead to harm, I want to tell you that I acknowledge it.
00:42:52
Speaker
And as an institution, we acknowledge it.
00:42:53
Speaker
We're not trying to hide anything.
00:42:55
Speaker
It will be as transparent with you as possible.
00:42:58
Speaker
It is fascinating now that in most of America,
00:43:02
Speaker
The patients and the patient's families have access to the medical record.
00:43:07
Speaker
So at times people will come and approach me and say, I don't understand why this is said.
00:43:12
Speaker
Can you help us understand?
00:43:13
Speaker
So having a very open relationship with families is important.
00:43:20
Speaker
And I think that what I'm hearing here, Nitin, is that be very clear and concise with non-medical jargon.
00:43:28
Speaker
What happened?
00:43:29
Speaker
What is the implication for the patient?
00:43:32
Speaker
And I think also very important to list the steps that we're taking to remediate or make things better, right?
00:43:41
Speaker
And the follow-up that they'll have.
00:43:43
Speaker
So being just, like you said, clear and really thinking about providing the right information in a compassionate way.
00:43:49
Speaker
But
00:43:50
Speaker
like you said, and being very precise with what you're saying.
00:43:53
Speaker
Yeah.
00:43:55
Speaker
And, and, uh, you know, disclosing, apologizing, I think are important.
00:44:01
Speaker
I think any clinician thinks about the medical legal ramifications, but at that moment, what you need to do is just be, um, transparent and truthful and whatever may come may come.
00:44:18
Speaker
Uh, but, uh,
00:44:19
Speaker
We all took the Hippocratic Oath.
00:44:22
Speaker
Our duty is to protect.
00:44:25
Speaker
And this is common, right?
00:44:27
Speaker
I mean, the Harvard Medical Practice Study from, I think earlier this year, it was in January.
00:44:32
Speaker
It's one out of four patients.
00:44:33
Speaker
This is not a rare occurrence.
00:44:36
Speaker
So...
00:44:39
Speaker
I think that we as a practice or as clinicians need to understand that it's common and we make mistakes and be transparent about it.
00:44:52
Speaker
I also think that I like what you said about medical jargon.
00:44:59
Speaker
Sometimes we will go into our heads and use a lot of medical words, but explaining in language that the patients can understand is important.
00:45:12
Speaker
Some would argue that at a fifth grade level probably is where you should target if you're explaining something like this.
00:45:19
Speaker
And I believe that also the other comment I want to make, Nathan, you mentioned the medical legal.
00:45:25
Speaker
I think the literature that's available is quite clear that transparent and timely communication will decrease the likelihood that you will be involved in legal problems.
00:45:35
Speaker
It doesn't obviously print 100%, but I think it definitely will decrease.
00:45:40
Speaker
And actually...
00:45:42
Speaker
University of Michigan has had a program that they're self-insured and they have a very robust and a very active process of disclosing medical errors in the hospital.
00:45:55
Speaker
And since they went that route, they have noticed that their legal issues have decreased significantly.
00:46:01
Speaker
So I
00:46:02
Speaker
I think that silence is probably much more likely to lead to malpractice issues.
00:46:08
Speaker
And like you said, I mean, we took an oath and we should always be very, very straightforward and clear with people on what's going on with their loved ones.
00:46:18
Speaker
Yeah, we, um, uh, the hospital on that, um, Cooper, um, health system, uh, we have a, uh,
00:46:28
Speaker
A standardized note for disclosure, and then you're supposed to notify your chief of service if a disclosure has been made.
00:46:39
Speaker
And then there's a process you follow, which is on the back of the badges, an extra card that I give to my faculty, advanced practice providers and fellows.
00:46:51
Speaker
because what you want is in that moment of panic, you want to have a playbook that can be followed and be transparent.
00:47:02
Speaker
Michigan, they've published literature on what they've done, and Cooper is similarly self-insured and follows a similar playbook.
00:47:09
Speaker
And it's, you know, as institutionally, I like being in an institution like that.
00:47:17
Speaker
Excellent.
00:47:18
Speaker
Well, we talked a little bit about some of the important aspects for the clinician, including being kind to yourself and recognizing that clinicians are also victims of medical errors, especially when they happen, I mean, to themselves and how to deal with
Leadership and Learning from Errors
00:47:34
Speaker
that.
00:47:34
Speaker
We talked about the importance of being kind to others and being more curious about medical errors with the intention of learning from them.
00:47:42
Speaker
And we talked about disclosing medical errors to patients and families.
00:47:46
Speaker
You're a leader of a critical care division, of a critical care center.
00:47:51
Speaker
As a leader, what are things that you're focusing on to try to improve safety for our patients and decrease medical errors?
00:47:59
Speaker
Yeah, one of the advances that I've seen over my career is the system for reporting errors and for errors –
00:48:11
Speaker
than to be thought about in a global manner.
00:48:15
Speaker
Like there's a process around it.
00:48:16
Speaker
So at my institution, it's called the EARS system.
00:48:23
Speaker
I think it's important to, if you are not in a place that you're able to report errors in a standardized fashion and those errors can be queried and be thought about, then to speak up and say, listen, I've heard that other institutions do this.
00:48:44
Speaker
How can we gain access to
00:48:47
Speaker
an anonymous way to report errors and I also would like to know the outcomes of those conversations.
00:48:56
Speaker
I think also as a leader, a true leader facilitates conversations or things that quote-unquote a leader may not want to necessarily hear and
00:49:11
Speaker
you know, if the dirty laundry is aired, um, it allows, uh, conversations on how to improve practice.
00:49:18
Speaker
Cause you know, patients are at the center of the conversation.
00:49:24
Speaker
Um, and then, um,
00:49:27
Speaker
I think there's important to know the difference between as a leader, and also this is very important for a bedside clinician, the difference between speaking up about a problem, being thoughtful, and complaining.
00:49:42
Speaker
And that if you are speaking about a problem and you've shifted over more to...
00:49:49
Speaker
Just complaining that, you know, the concept of psychological safety allows you to speak up, but it doesn't necessarily protect your right to speak, but it doesn't necessarily protect your right to, you know, speak illy of others or cycle into a negative spiral.
00:50:09
Speaker
So as a leader to promote open and honest discourse, but also for your colleagues to know that if you're going to go into an unproductive cycle, that as a leader, you probably stop that.
00:50:29
Speaker
But the worst thing you can have is have a meeting, an important meeting, and no one speaks because that's a sign that people don't feel safe to speak or
00:50:40
Speaker
When they speak up, it's useless.
00:50:42
Speaker
And if that's what's happening at you or your institution, you need to re-engage to see why you're not hearing other people's voices in the room.
00:50:52
Speaker
Absolutely.
00:50:53
Speaker
And I think that another important aspect of this is that you did mention that we all are part of the problem.
00:51:02
Speaker
Every clinician will commit medical errors.
00:51:06
Speaker
So I believe that short of just complaining, they should be part of the solution, right?
00:51:11
Speaker
And this is something that actively should engage everybody in trying to make care better.
00:51:15
Speaker
And that is part of being in a high-performing critical care team that requires psychological safety as its first ingredient.
00:51:23
Speaker
But I agree, I mean, that at the end of the day, we can't solve things unless we're working together as a team in the ICU.
00:51:33
Speaker
Nitin, this is obviously a super important topic.
00:51:36
Speaker
I appreciate you taking the time to talk with us about it.
00:51:39
Speaker
We'll have links to the articles you mentioned, to some other resources.
00:51:43
Speaker
You've been on the podcast before, so you know that we like to close with a couple of questions that are unrelated to the clinical topic, but that kind of tap into your wisdom.
00:51:52
Speaker
Would that be okay?
00:51:54
Speaker
Yeah, yeah.
00:51:55
Speaker
No, no, no.
00:51:55
Speaker
My wisdom is on short supply, but I'll do my best.
00:51:59
Speaker
So the first question relates to books.
00:52:01
Speaker
Are there any books or book that has influenced you significantly recently that you have gifted to others recently?
00:52:14
Speaker
You know, I would say that I enjoy fiction and literature.
00:52:21
Speaker
So,
00:52:22
Speaker
I really enjoyed reading Pachinko, and I think it became like an HBO teleseries or something like that.
00:52:33
Speaker
But just the history of basically, you know, Southeast Asia during World War II.
00:52:44
Speaker
And I've gifted that book to a couple people because it's just an amazing read.
00:52:48
Speaker
But it's also...
00:52:50
Speaker
insightful way to understand that part of the world is part of the world that I'm not from.
00:52:55
Speaker
Excellent.
00:52:56
Speaker
Second question.
00:52:58
Speaker
What do you believe to be true in medicine or life that most other people don't believe, or at least don't act like they believe?
00:53:08
Speaker
Um, I don't know if everyone embraces this, but I, it's, it's something that, uh, I sort of live my life by that, uh, uh,
00:53:20
Speaker
problems or opportunities like you know if i have a problem or there's failure at you know my immediate reaction is like oh my god this is terrible and then i take a step back and be like well you know how do i turn this around to make it an opportunity and um you know career-wise that's uh
00:53:42
Speaker
We had patients with ARDS.
00:53:43
Speaker
We were transferring out of the hospital for ECMO, and I said, you know, this is an opportunity to build an ECMO program.
00:53:48
Speaker
How do I do that?
00:53:50
Speaker
And it has been – it's really been a useful tool for me.
00:53:56
Speaker
And I think that also, obviously, very, very applicable to what we're talking about today.
00:54:02
Speaker
Any medical error, any failure is an opportunity to learn how we can do things better for more patients.
00:54:08
Speaker
And I think that that humility, that growth mindset is something that we all need as clinicians, but also as leaders.
00:54:15
Speaker
And the last question would be, what would you want every intensivist and APP that's listening to us today to know?
00:54:22
Speaker
Could be a quote, a fact, or just a thought.
00:54:29
Speaker
I would want them to know that you are my friend and a very thoughtful person.
00:54:39
Speaker
And it's been a tremendous honor and opportunity to know you and listen to you as the years have gone on.
00:54:48
Speaker
Well, thank you very much.
00:54:49
Speaker
Same here.
00:54:50
Speaker
I really always enjoy spending time with you, whether it be on the podcast or in person.
00:54:55
Speaker
Appreciate you sharing such an important topic with us today and looking forward to having you back.
00:55:02
Speaker
I appreciate it.
00:55:03
Speaker
Sergio, you take care.
00:55:05
Speaker
Take care.
00:55:06
Speaker
Thank you.
00:55:09
Speaker
Thank you for listening to Critical Matters, a sound podcast.
00:55:13
Speaker
Make sure to subscribe to Critical Matters on Apple or Google Podcasts and share with your network.
00:55:19
Speaker
Sound's transforming the way critical care is provided in hospitals across the country.
00:55:23
Speaker
To learn more, visit www.soundphysicians.com.