November, 1999 was a watershed for physicians. It is then that the infamous “To Err is Human” report was issued by the Institute of Medicine claiming that close to 100,000 patients were needlessly dying due to preventable medical errors. The report was a bombshell, having a significant impact on how medicine was practiced. 15 years later we are still evaluating that impact.
To anyone who took the time to read the report it was clear that it was problematic. However, being the complacent lemmings that we are, the report was accepted at face value. One problem was the fact that we as physicians failed to counteract the impression that we were at best complacent, at worst ignoring the effect these “errors” were having on our patients. Damage to our reputations and malpractice aside, the vast majority of physicians were well aware of these issues and were taking steps to prevent them.
However, there was a much bigger problem. Vague at best, the report failed to distinguish between an error and a complication. Wrong site surgeries, incorrect blood typing, and medication errors are, at least theoretically, 100% preventable. Post-op infections, DVT/PEs, however, are not. No matter. Once both got painted with the same brush the inevitable problems ensued.
After some initial success, a mad dash occurred to try and eliminate every so-called error. Medicares refusal to pay for these errors was one example. Worse still, when something was declared an error it immediately became a “never” event, something that had to be eliminated at all costs, even if that action put the patient at a different risk that is not considered.
Take venous thromboembolic prophylaxis. From the first days of orthopedic residency, we are well aware that our patients are at risk for blood clots in the legs with the possibility of death due one of those breaking off and lodging in the lungs (DVT/PE).
However, since the treatment involves giving the patients blood thinners, we are also well aware that there is a delicate balance between protecting the patient and preventing excessive bleeding. With time and experience, most surgeons learned what balance worked for them.
There is no way to completely eliminate DVT/PE risk. No matter. Once they were declared a never event a heavy thumb came down on the prevention side of the scale meaning the bleeding side went straight up, aggravated by the fact that the bleeding risk is not considered by whatever protocol had been set up.
15 years later, most physicians are living under a mountain of protocols and have been able to evaluate the effect they have had on how they practice medicine. The conclusion: It is rare that the protocol actually improved upon what they were already doing. At best following the protocol confirmed what they were already doing. At worst they have found that the protocol puts their patients at additional and unnecessary risk.
Today, physicians are widely criticized for not being patient centered. We are losing the battle between a physician doing what their training and experience tells them what needs to be done, and towing the company line. “To Err is Human” may be true, but if we don’t properly identify what the “err” is, it does no one any good.
Thomas D. Guastavino is a physician.
