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Medical Errors
18 Plays6 years ago
In this episode of Critical Matters, we discuss medical errors in healthcare. Our guest is Dr. Nitin Puri, a practicing intensivist and medical educator at the Cooper Medical School of Rowan University and the Cooper Health System in Camden, New Jersey. We discuss a range of topics related to medical errors in critical care medicine including the incidence of errors in our practice, causes, how to prevent them, and how we should deal with them when they occur.
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
Books Mentioned in This Episode:
Haroun and the Sea of Stories: https://www.amazon.com/Haroun-Sea-Stories-Salman-Rushdie/dp/0140157379/ref=asap_bc?ie=UTF8
Invisible Man: https://www.amazon.com/Invisible-Vintage-International-Ralph-Ellison-ebook/dp/B003WUYR9K/ref=sr_1_2?ie=UTF8&qid=1525281632&sr=8-2&keywords=invisible+man+ralph+ellison
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Transcript
Introduction to Critical Matters Podcast
00:00:09
Speaker
Welcome to Critical Matters, a sound critical care podcast covering a broad range of topics related to the practice of intensive care medicine.
00:00:17
Speaker
And now, your host, Dr. Sergio Zanotti.
Impact of the 'To Err is Human' Report
00:00:23
Speaker
In 1999, the Institute of Medicine released a landmark report entitled To Err as Human, Building a Safer Health System.
00:00:30
Speaker
The report stated that errors caused between 44,000 and 98,000 deaths every year in American hospitals and over 1 million injuries.
00:00:40
Speaker
This report was a catalyst for all the efforts we see today in patient safety.
Meet Dr. Nitin Puri
00:00:45
Speaker
The topic for critical matters today is medical errors.
00:00:49
Speaker
It's a pleasure to have as our guest Dr. Nitin Puri, who's Associate Professor of Medicine, Program Director of Critical Care Medicine at Cooper Medical School of Rowan University and Cooper University Healthcare.
00:01:01
Speaker
Dr. Puri is an accomplished clinician and medical educator.
00:01:04
Speaker
He's board certified in internal medicine, pulmonary disease,
00:01:08
Speaker
critical care and neurocritical care.
00:01:09
Speaker
Dr. Puri runs a nationally recognized fellowship program in critical care medicine and works clinically in the medical surgical intensive care unit at Cooper Healthcare System.
00:01:20
Speaker
He has a special interest in medical education, point of care ultrasound, and mechanically circulatory support.
00:01:26
Speaker
Nathan, welcome to Critical Matters.
00:01:29
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Sergio, thank you for having me.
00:01:31
Speaker
A true pleasure.
00:01:32
Speaker
So today our topic is medical errors, and I wanted to know
00:01:36
Speaker
as a beginning question, how did you get interested in this topic, Nitin?
00:01:42
Speaker
Well, um, I think because I make a lot of errors, so I had to figure out a way to forgive myself.
00:01:50
Speaker
And I figured that you would be an empiric expert as opposed to a theoretical expert.
00:01:54
Speaker
But what else is important about this as you, as it, for you as an educator?
00:02:00
Speaker
You know, um, in reality and also in all seriousness, um,
00:02:06
Speaker
I found myself as a person who has extreme attention to detail when caring for patients and taking care of other people's loved ones, that occasionally errors would be made.
00:02:20
Speaker
And I found myself very frustrated and I realized that I needed to learn more about the topic because
00:02:29
Speaker
I was very interested in improving the quality of care that I provide for patients.
00:02:32
Speaker
And then as I evolved as an educator, I found my trainees on the receiving end of either caring for patients where errors were made or errors they made themselves and seeing their own personal struggle with it made me realize that there was a tremendous opportunity to be able to help both the patients and my trainees.
00:02:55
Speaker
And I think that I trained before the report from the Institute of Medicine came out.
00:03:01
Speaker
I was in training when it came out.
00:03:02
Speaker
And it's very interesting, two decades later, how much has changed and how much has improved, but yet there's still a lot for us to do in this respect.
00:03:10
Speaker
And I hope that we can tackle some of those issues today.
Preventable vs. Unavoidable Medical Errors
00:03:16
Speaker
So my first question, Nitin, is how would you define a medical error and how is that different from an adverse event?
00:03:24
Speaker
I think that's an important question.
00:03:27
Speaker
I think the best way to define it is to give an example.
00:03:31
Speaker
An adverse event would be, let's say, a blood transfusion that's given to a patient and the patient has a reaction to the blood transfusion but everything was done correctly.
00:03:45
Speaker
That is a non-preventable adverse event, at least with the knowledge that we have currently.
00:03:53
Speaker
Medical error, if I was to again use another example, would be somebody placing a central line, perhaps giving a patient a pneumothorax, you know, was there opportunity around technique, was there opportunity around the site chosen, and that would be a medical error.
00:04:12
Speaker
So a medical error is a preventable complication
00:04:18
Speaker
or mistake that occurred while enacting patient care while an adverse event is a deleterious event that occurred to patients but perhaps not preventable.
00:04:32
Speaker
So in terms of errors and adverse events, clearly both are associated with poor outcomes for our patients in terms of
00:04:40
Speaker
an unexpected outcome, but the real question resides in was there a process error or was it something that could have been differently to prevent that or mitigate that outcome.
00:04:53
Speaker
And I think this is important because it's something that we know is very common in our practices, especially in critical care.
00:05:00
Speaker
Errors are committed either by commission or omission, and I think that it's something that we have to deal with and we have not probably dealt in the best way.
00:05:10
Speaker
Since we've defined medical errors, let's move a little bit forward in terms of how frequent are these really in practice?
Are Medical Errors a Leading Cause of Death?
00:05:18
Speaker
I recently read a report that cited that medical errors or preventable medical errors are the third cause of death in the U.S. Can you expand on that, Nitin?
00:05:30
Speaker
Yeah, that report has caused a significant amount of controversy in the medical literature and
00:05:39
Speaker
you know, the reason that it's so controversial is that, you know, methodology for obtaining that number, it wasn't that, you know, a large number of medical records were reviewed, medical errors were found, and then that number was extrapolated from.
00:05:56
Speaker
It was taken after analysis of a certain amount of
00:06:01
Speaker
medical literature studies examining errors that were done.
00:06:06
Speaker
And even from the previous to Error is Human, again, that was extrapolation of previous medical literature that was done that, you know, medical errors were a frequent cause of death.
00:06:20
Speaker
The problem is that even with the original report to Error is Human that the Institute of Medicine published, it was picked up by the popular press.
00:06:31
Speaker
And once it was picked up by the popular press, the physicians felt under siege.
00:06:35
Speaker
So the interface of retrospective literature being extrapolated as the cause to show that there's a large number of deaths in the United States caused by medical error then being picked up by the popular press obscured
00:06:56
Speaker
something which is a very important fact going on in America is that many medical errors are made every day in the United States and patient harm is caused and it's very important to address these errors and see what we can do about them.
00:07:12
Speaker
So if you had to throw a number out, what would be the number that people cite?
00:07:19
Speaker
For the amount of deaths caused by medical errors in the United States?
00:07:22
Speaker
Yes.
00:07:25
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You know,
00:07:27
Speaker
That's difficult to say.
00:07:30
Speaker
I will tell you that the physician safety study that was part of a work-over study that was done at Harvard with a couple of physicians reviewing medical records, that is probably the best literature, I think, about medical errors and that was prior to the institution of electronic medical records.
00:07:57
Speaker
You know, I think percentage-wise, it's tough to define, but, you know, people talk about 200,000 people perhaps having harm or losing their life second to medical errors.
00:08:10
Speaker
I'm not sure if that number is higher or lower because we have the inability to quantify it.
00:08:15
Speaker
And I think that a good point that a lot of people have made, Nitin, is that even though that number of 200,000 comes with some potential risk
00:08:25
Speaker
problems and methodology, it's also likely that medical errors, as we all know, are grossly underreported.
00:08:35
Speaker
I could not agree with you more.
00:08:38
Speaker
But I think that it's fair to say that we all have seen them in our practice.
00:08:43
Speaker
that some people think that it's a leading cause of death in the United States.
00:08:47
Speaker
It's a real problem.
00:08:49
Speaker
And like you pointed out, the real number we don't have right now, but a number that's frequently recorded in the literature is 200,000 deaths from medical errors annually in the United States.
Hospital Strategies to Address Medical Errors
00:09:02
Speaker
So,
00:09:03
Speaker
Let's move to what we can do to improve this from a system level.
00:09:07
Speaker
I think that, Nathan, that we have been trained in medicine, especially in critical care, to be heroes.
00:09:14
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And I think that medical errors or dealing with medical errors really does not require heroes, but requires a lot of humility.
00:09:21
Speaker
And I think that's been a big...
00:09:23
Speaker
switch in our chip that has been very difficult.
00:09:27
Speaker
Talk a little bit about what you think hospitals should be doing or ICUs at a system level to deal with these medical errors.
00:09:35
Speaker
Yeah, you know, one thing that's happened in hospitals has been the institution of patient safety officers and actually taking a critical analysis of medical errors.
00:09:50
Speaker
You know, the Agency for Quality and Healthcare Research, there has been a significant amount of funding to look at medical errors that started since 1999.
00:10:00
Speaker
And what's fascinating is if you look from 1999 to now to 2018, if you believe the medical literature and the methodology used, there's significantly more errors today than occurred in 1999.
00:10:17
Speaker
I don't think that that's what's occurred, I think we're just more aware of them.
00:10:20
Speaker
And so the institution, again, a patient safety officer, anonymous reporting system, support systems for those when medical errors are made, and honest interactions and reporting to both the medical staff and the patient after an error has occurred, and education about medical errors for the house staff, and attending physicians who may have trained in error prior to
00:10:46
Speaker
acknowledging that you made an error was the correct thing to do is very important.
Causes of Medical Errors
00:10:54
Speaker
What are considered like the top causes of medical errors according to the literature?
00:11:01
Speaker
So there are two primary things that I think are very important is that one is the failure to implement a plan.
00:11:10
Speaker
I think in the intensive care unit there's much more time spent
00:11:14
Speaker
talking about a plan as opposed to implementing a plan.
00:11:18
Speaker
And I think that clinicians need to be aware of that and actually in a teaching institution now, I think it's important to define the definition of work rounds versus educational rounds.
00:11:32
Speaker
So when I round after making myself more aware of this literature and examining it more closely,
00:11:39
Speaker
I try to use closed-loop communication, a repeat after what I've talked about, that the plan is going to be enacted, that the nurse understands what the plan is, the intern has put in the orders, and that we're all aware what the plan should look like for the day.
00:11:57
Speaker
large cause of medical errors is medication safety events.
00:12:03
Speaker
That has improved significantly over the past 20 years.
00:12:08
Speaker
I think the role of clinical pharmacists on rounds in the intensive care unit, there's pretty good literature to support clinical pharmacists being involved in the delivery of critical care and patient safety mechanisms that exist that made a significant improvement
00:12:27
Speaker
But then you get into the gray area, right, of, you know, somebody's critically ill and the team believes that the family of this critically ill patient should progress to comfort care or withdrawal support and they, you know, are trying to be empathetic.
00:12:50
Speaker
but the patient needs a new IV access and central lines placed and again gives a pneumothorax to a patient.
00:13:00
Speaker
Now, a physician may say, often you hear a physician saying, well, the patient was going to pass anyways and this complication was a part of their course.
00:13:12
Speaker
Don't be upset about it.
00:13:13
Speaker
That's what older physicians may say to younger physicians.
00:13:16
Speaker
But is that the right thing?
00:13:18
Speaker
Is that correct?
00:13:19
Speaker
So again, like you were talking about earlier, and I acknowledged too, perhaps the number of errors are significantly larger than we even recognize.
00:13:27
Speaker
And I think that you touched on a couple of things that I want to dig in a little bit more or reemphasize that are very important.
00:13:34
Speaker
So first, I think that in terms of broad categories, we talked earlier and you mentioned errors of omission versus errors of commission, right?
00:13:43
Speaker
And you mentioned both.
00:13:45
Speaker
So in terms of omission, it seems like, I mean, not implementing a plan as we have outlined or the appropriate plan based on standards of care is something that probably occurs more frequently than
00:13:57
Speaker
Then we report, and I suspect, Nathan, that, for example, if a patient has a cardiac arrest and we say, let's start hypothermia or target temperature management, and they come from the ED, go to the ICU, and there's a four-hour delay in initiating that therapy.
00:14:18
Speaker
We start it late.
00:14:20
Speaker
It's hard to measure the impact of that on patients, but that would be an error, right?
00:14:25
Speaker
That is correct.
00:14:27
Speaker
That is correct.
00:14:29
Speaker
And I think that what's interesting is that my question would be, what is the main cause of that type of error in your opinion?
00:14:36
Speaker
Yeah, you know, um, that's also a very important cause of errors.
00:14:41
Speaker
Um, and, uh, it's, uh, a cause that's gotten quite a bit of, um, uh, press recognition and, uh, you know, the, the implementation of I-PASS, uh,
00:14:54
Speaker
basically a standardized communication tool for handoff.
00:14:59
Speaker
I believe handoff between clinicians also is a major cause of errors.
00:15:05
Speaker
And what it is is that, and this falls in terms of under the failure to implement, is that a decision is made in the emergency room that the patient needs to get targeted temperature management, but
00:15:18
Speaker
the plan has a failure to implement because the clinicians changed from the emergency room up to the intensive care unit and the handoff that occurred was poor or was incorrect.
00:15:30
Speaker
And that occurs daily in intensive care units and hospitals around the world.
00:15:36
Speaker
And trying to create a system of appropriate handoff and closed loop communication
00:15:46
Speaker
is the best way to be able to try to prevent that.
00:15:48
Speaker
And there's good medical literature about using standardized handoff tools to improve communication.
00:15:56
Speaker
And I think that communication seems to be, at the essence, the problem here.
00:16:00
Speaker
And it's interesting with all the advances in technology, we seem to be falling behind in communicating effectively and consistently with our fellow colleagues.
00:16:12
Speaker
But can you talk a little bit about...
00:16:15
Speaker
The closed loop or things that you might implement in the ICU that would help with improving communication between physicians or between physicians and other members of the ICU team, like the respiratory therapist, the nurses, clinical pharmacists, et cetera?
Improving ICU Care with Communication and Checklists
00:16:32
Speaker
Yeah.
00:16:32
Speaker
Yeah.
00:16:34
Speaker
One of the things that seems to make a big difference is at the end of rounds is the, depending on your setting, so I practice in the academic medical center with the multidisciplinary team.
00:16:48
Speaker
At the end of the rounds, we often emphasize our nursing staff repeating the plan for the day for the patient, what was discussed, we summarized.
00:16:59
Speaker
what went on and what needs to be done for the day and then also give our colleagues, our nursing colleagues, the authorization to hold us to test that the plan is enacted and occurs during the day.
00:17:16
Speaker
One of our colleagues came up with a tool called Faster Flag, which is a form of a checklist and I think that that has been
00:17:25
Speaker
an effective tool for us at Cooper to make sure that we hit many of the central elements of care.
00:17:34
Speaker
F stands for feeding, A is for analgesia, S for sedation.
00:17:38
Speaker
That's for both our CAM ICU and RAS scores.
00:17:45
Speaker
T for DVT prophylaxis, E for extubate, talking about the plan of ventilator, R for restraints.
00:17:53
Speaker
are they needed, what are you doing with them?
00:17:55
Speaker
F for Foley, is it needed or not needed?
00:17:58
Speaker
L for lines, number of days of having a line, do you need the line?
00:18:03
Speaker
A for activity, working on a progressive mobility protocol, and G for blood sugar.
00:18:09
Speaker
And so, at least those core elements are reviewed at the end of every patient, and then we talk about the plan for the day, and that's made a big difference.
00:18:20
Speaker
And that's what I mean about close communication is that
00:18:23
Speaker
It's the simple elements that are repeated over and over again on rounds to make sure that we're all on the same page.
00:18:29
Speaker
And I think that it's really about producing reproducible elements
00:18:33
Speaker
systems that recognize that the fallibility of human beings in terms of our behavior, I think that we all agree that none of us want to harm patients, yet on a regular basis, like you said, patients are being harmed.
00:18:47
Speaker
And I think this is something that we have learned from other industries and really trying to be more process-oriented in terms of providing safety.
00:18:54
Speaker
So let's move on to a little bit of another topic within this discussion,
Learning from Medical Mistakes
00:19:00
Speaker
Nitin.
00:19:00
Speaker
And once an error has occurred,
00:19:03
Speaker
How do systems or hospitals or ICUs, how should they be handling that?
00:19:10
Speaker
Yeah, that's a great question.
00:19:13
Speaker
I found myself totally unprepared to deal with medical errors when I went out into the workforce in 2011.
00:19:25
Speaker
I...
00:19:32
Speaker
And the reason was is that I perceive myself as an empathetic person, as a caring person.
00:19:41
Speaker
And I also try to treat patients like I would treat my own family members.
00:19:48
Speaker
And when I was
00:19:52
Speaker
When I saw I was part of a medical error, I was unduly harsh on myself and sought to, went through a whole range of motions.
00:20:05
Speaker
First, like, should I speak to the family, should I not speak to the family?
00:20:09
Speaker
How should it be documented in the medical chart?
00:20:10
Speaker
Should it be documented in the medical chart?
00:20:13
Speaker
You know, I'm embarrassed in front of my colleagues.
00:20:15
Speaker
Should I acknowledge this in front of my colleagues?
00:20:17
Speaker
And what I did was, is actually in a large community hospital where I started my practice initially, I initiated and created a morbidity and mortality program.
00:20:29
Speaker
And I think like a lot of physicians who are caring, I would routinely bring up my own cases while my other colleagues would not bring up their cases.
00:20:38
Speaker
I'd discuss them.
00:20:39
Speaker
But what I found is it was making me a better physician.
00:20:42
Speaker
And I would understand errors that I had made.
00:20:45
Speaker
and that I may not realize it had even made at the time.
00:20:50
Speaker
Then, over a period of time, I recognized that when errors were made and I did recognize them, that I need to be able to discuss with patients' families, make sure that they're aware that errors had occurred.
00:21:05
Speaker
And actually, it was a sense of liberation and freedom.
00:21:12
Speaker
I realized that teaching that in education, educating my fellows and how staff about that process today is very, very important.
00:21:20
Speaker
And I think that that's a very important point, Nitin.
00:21:23
Speaker
And I think that most of us were not trained to handle medical errors.
00:21:29
Speaker
We actually were led to believe that it's best not sometimes to disclose or to avoid discussing or bringing them up.
00:21:38
Speaker
But I do believe that, like you said, that the ideal situation is when people are self-reporting with the intention of really improving.
00:21:46
Speaker
And I think that that's the goal at the end of the day that we should all have.
00:21:50
Speaker
And I think that really requires us from taking off our hero caps as ICU physicians and being very humble and recognizing that there's a lot more than we don't know than we do know.
00:22:02
Speaker
And that is likely that we will make a lot more errors in the future.
00:22:05
Speaker
But the goal is to keep improving.
00:22:08
Speaker
Yeah, and there was a, there's some literature from JAMA about speaking to outpatient internists, and I can't remember how old the paper is, maybe 10 years, and the internists were very clear that a majority of the time they would not report their medical error or they would, because they weren't sure that the public wanted to hear the medical error.
00:22:37
Speaker
and that they weren't sure the public would understand the medical error or the patient would understand the medical error.
00:22:44
Speaker
But there's also literature that patients want to know that if an error has been made, they want it to be acknowledged and they want to have trust and confidence in their physicians.
00:22:57
Speaker
The most trusted profession in the United States are nurses.
00:23:03
Speaker
And the reason nurses are most trusted in the position is that
00:23:06
Speaker
Patients and patients' families feel that nurses are advocating for their patients.
00:23:11
Speaker
Physicians are, I think, in the top five, I think number four, but families want to feel that they can trust their position, and an important part of trust in that trusting relationship is acknowledging when mistakes have been made.
00:23:24
Speaker
I think that's a very important point.
00:23:26
Speaker
And like you said, in my read of the literature, what matters to patients are four things.
00:23:33
Speaker
That there's disclosure of all harmful errors they want to know.
00:23:37
Speaker
Number two, that there's an explanation as to why the error occurred with facts.
00:23:45
Speaker
they are told how the effects of the error will be mitigated or will be done by the doctors to minimize the effects of the error.
00:23:53
Speaker
And I think something that's very important, even when outcomes are very, very poor, is they want to know what steps the physician and the institution will take to prevent a recurrence of the same error.
00:24:06
Speaker
And I think that that's something that we sometimes underestimate how important it is for patients.
00:24:11
Speaker
Any comments from your standpoint on that, Nitin?
00:24:15
Speaker
You know, my only comment about that is that I would acknowledge another piece of literature that exists about the moral distress that providers feel about medical errors.
00:24:29
Speaker
And unless they understand these basic facts that you just brought up,
00:24:37
Speaker
they will not have the tools to be able to deal with medical errors going forward.
00:24:41
Speaker
I think it's a vital part of medical education, both for trainees and physicians who are practicing.
00:24:48
Speaker
Because what are we all worried about at the end of the day?
00:24:51
Speaker
We're all worried, well not all worried, but I can tell you it's in the back of my mind.
00:24:56
Speaker
I worry about getting sued, right?
00:24:58
Speaker
Acknowledging to a family, I made a mistake, I'm gonna get sued.
00:25:02
Speaker
My trainees are worried about that all the time too.
00:25:05
Speaker
that gets in the way of the delivery of care.
00:25:08
Speaker
And I think that that's a very complex topic, the interaction of medical legal liability and having a therapeutic and trusting relationship with patients' families.
00:25:21
Speaker
And I think it's pretty clear that acknowledge medical errors are made, families are going to have more trust and more belief in you that you're going to do the right thing for
00:25:30
Speaker
And I think that my interpretation of the literature is regarding the risk of litigation.
00:25:38
Speaker
Obviously, it's a real concern.
00:25:40
Speaker
When you disclose an error, it's a real possibility.
00:25:42
Speaker
But in hospitals or in systems like the University of Michigan, where they really have an open disclosure, a very aggressive way of telling patients about all the errors that occur,
00:25:53
Speaker
What they found is that litigation goes down and the cost for litigation goes down when people are very open and very clear and very honest with patients.
00:26:01
Speaker
And I think that in general, what has been shown to decrease the likelihood of litigation is communication with families and being straightforward of what's going on with them.
00:26:14
Speaker
Any comments on that aspect?
00:26:18
Speaker
No, no, I couldn't agree with you more.
00:26:21
Speaker
I think that the literature does support that having an honest, open, therapeutic relationship with families decreases the incidence and likelihood of litigation.
00:26:33
Speaker
And also, you know, remembering why you became a physician, having empathy for the patients and their families when errors are committed.
00:26:46
Speaker
and being able to communicate that with family is very important.
00:26:51
Speaker
Absolutely.
00:26:52
Speaker
I think another aspect that I wanted to ask you about disclosure has to do with, do you think that we should apologize to patients for what has happened when we disclose an error?
00:27:06
Speaker
I apologize to patients.
00:27:09
Speaker
You know, it matters on the...
00:27:13
Speaker
significance of the error.
00:27:15
Speaker
I think errors have different categories.
00:27:19
Speaker
there was the study at Hadassah again I can't I apologize I can't remember the years but I think now it's probably 15 to 20 years old looking at medical errors in the intensive care unit and using human factors as a role for preventing medical errors and you know the categories errors is you know different types is less serious to more serious and causing patient harm or not causing patient harm I think if you know you missed to replace a potassium
00:27:49
Speaker
and there's no medical error, no harm caused, it's probably not a lot to talk about with the family as opposed to you didn't replace potassium and they had a cardiac arrest.
00:28:00
Speaker
Then I think you need to acknowledge that the mistake was made and you need to make an apology and you have to rely on the basic human instinct of forgiveness.
00:28:12
Speaker
Because the person who's going to be hardest on you is yourself, right?
00:28:15
Speaker
Not the family's at the end of the day.
00:28:18
Speaker
Absolutely.
00:28:19
Speaker
What about documenting the chart?
00:28:23
Speaker
What are your thoughts on that?
00:28:25
Speaker
That's a good question.
00:28:27
Speaker
I know everyone's instinct is to not document in the chart or not acknowledge an error was made or use purposely vague language.
00:28:38
Speaker
I don't think that's right.
00:28:40
Speaker
I think that if an error is made, you need to acknowledge you made an error.
00:28:44
Speaker
And then those going forward need to recognize that an error was made
00:28:49
Speaker
and be able to treat the patient going forward because critical care is a team sport.
00:28:54
Speaker
It's a 24-7 process.
00:28:56
Speaker
And so everyone needs to understand what occurred, why it occurred, and how it was dealt with to be able to move forward.
00:29:04
Speaker
Otherwise, those problems could linger.
00:29:06
Speaker
Yeah.
00:29:07
Speaker
And I think that if one does a good job disclosing to the patient or the family the chart documentation to just reflect that conversation.
00:29:16
Speaker
And I think it should be factual and relay what was told to the family and the patient.
00:29:21
Speaker
And I agree that we have an obligation to the patients to disclose the errors.
00:29:27
Speaker
But also, I think we have an obligation to our colleagues to document in the chart what has happened so that they can take that into account when treating the patient.
00:29:38
Speaker
I think, Nitin, that we covered a lot of very important topics.
00:29:42
Speaker
Clearly, we talked about the prevalence of medical errors.
00:29:48
Speaker
We talked about how we define them, some of the causes, how we should be disclosing them to patients, what's important for patients, and some of the things that systems should be looking at.
Emotional Impact on Providers and Supportive Cultures
00:30:00
Speaker
But there's one thing that you mentioned that I would like to dive in a little bit more, which is the topic of moral distress for the provider.
00:30:09
Speaker
And often providers are considered second victims in these errors.
00:30:15
Speaker
And if you review this in the lay public,
00:30:19
Speaker
literature, there are very extreme cases of nurses who have committed suicide, doctors who have committed suicide after significant errors and after being publicly denounced for their errors.
00:30:35
Speaker
So clearly those are extreme cases, but I think that there's many more of our colleagues who are suffering in silence.
00:30:42
Speaker
Can you talk a little bit about this moral distress and the provider as a second victim?
00:30:48
Speaker
Yeah, this is very, very powerful when you're speaking about Sergio, especially I'm in the process of our, I currently, you know, are training critical care and public critical care fellows at Cooper.
00:31:04
Speaker
Providers, and we're humans, we make mistakes.
00:31:07
Speaker
That is the title of the 1999 report.
00:31:11
Speaker
To err is human.
00:31:13
Speaker
Errors don't occur secondary to
00:31:17
Speaker
medical providers, errors occur secondary to faulty systems.
00:31:22
Speaker
That was the point of the report.
00:31:25
Speaker
And weaknesses in the systems need to be analyzed, need to be improved.
00:31:32
Speaker
You need to do root cause analysis.
00:31:35
Speaker
You need to really understand why the error occurred and how you can improve the system.
00:31:40
Speaker
And providers will make individual mechanical mistakes if I'm placing a line.
00:31:47
Speaker
To suffer in silence is very dangerous and it's important that critical care providers have somebody to talk to.
00:31:57
Speaker
That's also part of the reason we try to work with them, to be able to speak with families and be able to be honest with them.
00:32:07
Speaker
Because, I'll be honest with you, even if, let's say, you were to suffer litigation because of a medical error you made,
00:32:17
Speaker
or because you were involved in medical error where the system failed you.
00:32:20
Speaker
At the end of the day, you have the ability to say, I was honest and I did my best.
00:32:26
Speaker
And I think that being able to be free of the burden of not feeling that you lied to anyone, not feeling that you deliberately covered a medical error is a tremendous relief on everyone's shoulders.
00:32:44
Speaker
And again, the literature supports this.
00:32:47
Speaker
Trainees, when they make errors, suffer significant moral distress and they need an outlet to be able to talk about it.
00:32:54
Speaker
And that doesn't change when you go into practice.
00:32:56
Speaker
Actually, in reality, it likely becomes worse because your outlets to be able to communicate becomes significantly less and less.
00:33:04
Speaker
And clearly, there's a great correlation with this type of moral distress and burnout, which is a topic that's very prevalent in critical care and in medicine in general.
00:33:16
Speaker
what do you recommend as outlets or, or things that we could implement outside of the context of a training program?
00:33:22
Speaker
Uh, you talked a little bit about what you did in your first job, but can you comment on that a little bit more Nitin?
00:33:29
Speaker
Yeah.
00:33:30
Speaker
Um, you mean outside of medicine or specifically within medicine?
00:33:34
Speaker
No, within the ICU, within medicine to deal with, um, providers, uh, and their, their, their relationship to medical errors.
00:33:43
Speaker
Yeah.
00:33:44
Speaker
I will tell you, um,
00:33:46
Speaker
There are a few things that I think are pretty important.
00:33:50
Speaker
I believe the culture you have in your intensive care unit is very important.
00:33:54
Speaker
I was trained by some very good physicians, Dr. Dellinger, you, Sergio, and a couple of other providers who created an environment of understanding and empathy.
00:34:11
Speaker
So when errors were made,
00:34:13
Speaker
They were not viewed, I was not viewed as an outlier or as a bad physician.
00:34:20
Speaker
I was viewed as somebody who was a trainee who made a mistake.
00:34:27
Speaker
And I think that that's very important.
00:34:28
Speaker
The culture that people are trained in or the culture which you practice in cannot be a vindictive culture.
00:34:35
Speaker
It has to be a supportive culture.
00:34:36
Speaker
So I think that's number one.
00:34:39
Speaker
Number two, there has to be the ability to exist for anonymous reporting systems, which I think many hospitals in the United States have today, where you can acknowledge an error was made.
00:34:52
Speaker
You don't necessarily have to say that you're the person who's acknowledging it and that people have the ability to go back and review the error by a third party.
00:35:06
Speaker
Number three is there has to be a support system for both the physicians, the nurses, or any clinical provider once errors have been made to be able to talk about it in a non-threatening environment.
00:35:18
Speaker
That goes back to number one, the supportive culture.
00:35:20
Speaker
But then there actually has to be the mechanisms in place besides
00:35:25
Speaker
physician who supports you, but whether it's the ability for employee assistance program, access to psychologists.
00:35:33
Speaker
But mental well-being is very, very important and it's the key to us being able to deliver good care because psychologically you've got to be in good place to be able to deliver good care to the critically ill.
00:35:49
Speaker
I think that we've touched on some very important topics.
00:35:52
Speaker
There's obviously a lot more to talk about, and we might do that in future episodes.
00:35:57
Speaker
But I think this is a good place to close, Nitin.
00:36:00
Speaker
And on critical matters, we usually like to finish with some questions that are not directly clinical but related to the practice of critical care.
00:36:09
Speaker
Would that be okay for you?
00:36:12
Speaker
That would be part of the question.
00:36:15
Speaker
So the first question, Ethan, is what book or books have influenced you the most or what book have you gifted most often to others?
00:36:27
Speaker
So currently, most of the books I give to others are storybooks for my little kids.
00:36:36
Speaker
So I'm
00:36:38
Speaker
I would assume these would be gifts that I'd give to adults.
00:36:42
Speaker
Often I found myself giving, in this current era, Harun and the Sea of Stories, a book by Salman Rushdie, where Rushdie wrote that book when he was under fatwa from the late Ayatollah Khomeini, and he wrote about the power of story.
00:37:06
Speaker
and There's a real famous quote from that book.
00:37:09
Speaker
What's the use of stories that aren't even true?
00:37:12
Speaker
And that's always stuck with me because in that book Rushdie who's made his life as a storyteller Defends the story and how important it is to life my favorite my favorite book is
00:37:27
Speaker
though is the book that opened my mind the most or still had the most impact on me was Invisible Man, which I read as a teenager and then reread about a decade later and it kept with me at all times because much like medical errors, it's when you don't acknowledge
00:37:50
Speaker
that there's a problem, it can erupt into a much larger problem.
00:37:54
Speaker
And so Ralph Ellison, I think, is one of the great writers of the 20th century.
00:37:59
Speaker
Absolutely.
00:38:00
Speaker
I think two excellent books.
00:38:01
Speaker
And I think that it also illustrates that there is much to be learned from fiction and that at the end of the day, we learn through stories both in life and in
Maintaining Trust in the Medical System
00:38:14
Speaker
medicine.
00:38:14
Speaker
So we'll add links to these two books in the show notes.
00:38:19
Speaker
Nitin, second question.
00:38:21
Speaker
What do you believe to be true in medicine or life that most other people don't believe?
00:38:33
Speaker
I think doctors know this.
00:38:38
Speaker
It's a famous quote from my mother to me in my own mind when I was struggling through medical school.
00:38:46
Speaker
She said to me, Nithin, I know many physicians who are much less intelligent than you.
00:38:53
Speaker
When I was saying that, I wasn't sure if I could make it.
00:38:57
Speaker
And I think to be a good physician, you need to be detail-oriented and you need to be able to focus.
00:39:05
Speaker
But it's not necessarily about your potential or your IQ.
00:39:10
Speaker
It's about following through on tasks and
00:39:15
Speaker
And again, like I'm saying, just be detail-oriented.
00:39:17
Speaker
So my point about that is I think the lay public sees intelligent physicians as very, very intelligent people or physicians as sort of stalwarts of society and what I view them as is people who are disciplined and are able to provide care for members of society because they have attention to detail.
00:39:41
Speaker
And I think to some extent, attention to detail for patient care is really caring about that human being and the dignity that they bring to the table, making sure that you're treating them like you said earlier, you would treat somebody who you love.
00:39:54
Speaker
I think that's very powerful and very important.
00:39:58
Speaker
So my last question, Ethan, what would you want every intensivist to listen to this podcast to know?
00:40:09
Speaker
To me,
00:40:10
Speaker
The most important part about this topic is as trust sort of erodes in institutions that historically have sort of been the pillars of Western society whether it's the news media, whether it's elements of the American military,
00:40:40
Speaker
I think medicine is not invulnerable to those concerns and it's happened already.
00:40:47
Speaker
The more money is spent on homeopathic medicine than I think allopathic medicine.
00:40:58
Speaker
And I believe that if we're not honest with our patients about mistakes we make or about our own failings,
00:41:10
Speaker
then they will lose trust in the medical system.
00:41:13
Speaker
And I think that would be a tragedy for modern humanity.
00:41:18
Speaker
And I think that's a great place to stop, Nitin.
00:41:21
Speaker
I think that we as a society would not accept the level of errors in other fields that are occurring in medicine.
00:41:32
Speaker
And when we're dealing with people's life, that is something that I think that we should really ponder and correct.
00:41:40
Speaker
I agree.
00:41:42
Speaker
Well, it's been a great pleasure, even though the topic obviously is a tough one.
00:41:46
Speaker
But I think that the message, Nathan, is that we should be aware that this is real, that we should own it, and that we should find ways to make it better for the providers, the patients, and make sure that we are very straightforward and honest.
00:42:02
Speaker
And at the end of the day, that the real goal is to provide the best patient care and for us to keep improving as physicians.
00:42:09
Speaker
Any other parting thoughts?
Lessons from the Aviation Industry
00:42:14
Speaker
I think a moral from the aviation industry, I don't want medicine to exactly replicate the aviation industry because it's sort of painful to fly, but this past month was the first death in nine years in a domestic aviation
00:42:40
Speaker
industry or accident and the domesticated ammunition industry that how amazing would it be if we could get medicine to go down that route and what what do we need to do to get there that's that's that's the challenge for your listeners what do we need to do to get there and I think that challenge accept it and we'll
00:43:01
Speaker
touch base soon again to talk more about more topics related to critical care.
00:43:06
Speaker
Nitin, it's been a pleasure.
00:43:07
Speaker
Thank you so much for your time and look forward to talking with you again.
00:43:10
Speaker
Hey, thanks, Sergio.
00:43:12
Speaker
You take care of yourself.
00:43:15
Speaker
Thanks again for listening to Critical Matters.
00:43:18
Speaker
Make sure to subscribe to this podcast on iTunes or Google Play.