A fascinating, beautifully-written article on a death penalty granted to a most likely innocent man, with interesting details on fire dynamics and the history of the judicial system pertaining to the death penalty.

Reading about the system in place that should prevent an innocent man from being wrongfully executed reminds me of the supposed system that prevents medical errors from occurring – both are imperfect, with innocent victims falling through the holes in the leaky swiss cheese model to the void of failure on the other side. It used to boggle my mind how the consecutive holes could all possibly align when each slice represents safeguards designed to compensate for failures of other steps in the series of prevention.

However, after being in the hospital, I realize the slices, unintentionally, have evolved to make for failures. Below are examples, in place at our hospital, of unfortunate happenings prone to encourage medical errors:

1. Barriers against effective communication

• Nurses who are primary caretakers of patients (administering drugs, collecting vital signs, administering neuro checks) are often too overworked to relay information to physicians who are decision makers in need of first-hand information on the patient. Many nurses could not finish progress notes on their patients, others are too overworked to answer questions or notify physicians of important mishaps during their shift.
• At our hospital, nurses change shift at the same time physicians round on patients – it is impossible to find nurses close to rounds to ask them about events overnight, day nurses often did not receive complete, important signouts from night nurses. Often times, important information is lost during shift changes.
• At our hospital, nurses are listed on the board next to their patients by only their last name, but all the ancillary staff on the floor call each other by their first names. Physicians trying to find a nurse for their patient will look on the board, ask around for nurses by their lastnames without an idea of their appearance and unable to call for them by first names. There have been suggestions that nurses are listed by their first names along with their contact info (beeper, voicera). It is a difficult feat.

2. Lack of continuity of care

• There have been cases of medical errors stemming from the change of medical teams or change of patient location. Many times when patients are off the floor for studies or dialysis, medications are held and not subsequently administered – there is no sign off between, for example, floor nurses and dialysis nurses to continue floor medications when patients are stuck on dialysis units for hours, missing scheduled floor medications. When medications are held, medical teams should be notified.
• At our hospital, residents are on clinic on post-call days, leaving the team, down one intern, to handle newly admitted patients unfamiliar to the less-experienced PAs and interns. A better system might be for residents to be on clinic on No Admit days, when both interns who had admitted the patients are around to provide continuity of care.

3. Lack of idiot-proof information system

• The information technology system in medicine really has to be idiot-proof, considering doctors take care of many patients, many of whom are not familiar to them. With a heavy load of patients, sleep-deprived doctors are trained to scan and scavenge information from different sources, creating a setup for human errors. Medication list/reconciliation has been a favorite area of mistakes – a good IT system should automatically reconcile medications and reduce human input to a minimum. It should also provide useful reminders to help prevent predictable sets of bad outcomes – for example, an order for insulin should prompt physicians to enter orders for parameters of when to hold insulin and what nursing should do in case of hypoglycemia. It should also ask physicians what to do in cases of hyperglycemia (i.e. give x units of insulin) and automatically sends off hyperglycemic labs (chemistry, urine ketones, etc). An admission order should prompt physicians to enter orders that are not directly related to medicine and are often forgotten, such as DVT prophylaxis, precautions, diets, etc.

4. Multiple opportunities for medical errors

• If a medical process, such as administering medications, involves 7 steps (ordering the right dose, pharmacists sending the correct drugs, nurse administering drugs to the right patient) and each step is performed correctly 99% of the time, the probability that the whole process is performed appropriately approaches 93%, and this probability exponentially reduces as more steps are introduced to the process. I think most people agree that we do not do our job correctly close to 99% of the time, and cutting down complicated steps can be helpful.

5. Lack of appropriate education

• Medical staff should be educated to recognize events resulting in potential errors and trained to respond in anticipation to prevent those adverse events. For example, if a patient fails to receive important medications when off the floor, nurses should recognize that such missed medications can cause significant outcomes and alert physicians so that they can appropriately respond (re-order medications, prophylaxis against complications). They should also convey these mishaps to ancillary staff in the next shift so that they are aware of potential complications developing as a result of inciting events occurring in prior shifts.

This is only a brief listing – various other ideas are not touched on here. The important step toward figuring out how to prevent medical errors is to learn from our mistakes – find out what had gone wrong and plug the leaky holes, incorporating inputs and encouraging communication among all parties involved.

In the case of this death row prisoner, errors stemmed from reliance on beliefs without regards to scientific evidence, and lack of interest/caring for the victim at hand – the same problems plague the medical system.

“angienadia” is an internal medicine physician who blogs at Primary Dx.

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