PAPER CUTS: First Do No Harm

Everyone makes mistakes once in a while. Auto mechanics put in 10W30 oil instead of 10W40, waiters bring you regular instead of decaf, and even newspapers like this one publish the occasional typographical error. But not a single one of these blunders is life threatening.Medical mistakes, on the other hand, result in the deaths of between 44,000 and 98,000 people in U.S. hospitals each year, according to a report released this past November by the Institute of Medicine of the National Academy of Sciences. On an annual basis, more people die from medical mistakes than from motor vehicle accidents, breast cancer, or AIDS.The NAS study stresses that the majority of medical errors are not due to individual recklessness, but result from basic flaws in the way the health system is organized. While errors may be more easily detected in hospitals, they afflict every health care setting: day-surgery and outpatient clinics, retail pharmacies, nursing homes, as well as home care. Both in and out of hospitals, more than 7000 die each year from medication errors alone.William Richardson, chairman of the study committee, states that health care is a decade or more behind other high-risk industries in its attention to ensuring basic safety. The chance of dying in a domestic airline flight or at the workplace has declined dramatically in recent decades, in part because of the creation of federal agencies that focus on safety, while deaths from medical errors continue to rise.Medical knowledge and technology (have grown) so rapidly that it is difficult for practitioners to keep up. And the health care system itself is evolving so quickly that it often lacks coordination. When a patient is treated by several practitioners, they often do not have complete information about the medicines prescribed or the patient's illnesses.Moreover, for most health care professionals, there is no assessment of clinical performance once they get their licenses to practice. Although previous findings suggest that only 3 to 5 percent of the physicians are responsible for the majority of malpractice, licensing and certifying bodies should implement periodic re-examinations of (all) doctors, nurses, and other key providers, based on both competence and knowledge of safety practices.The report concludes that these stunningly high rates of medical errors, resulting in deaths, permanent disability, and unnecessary suffering, are simply unacceptable in a medical system that promises first to do no harm. We must have a health care system that makes it easy to do things right and hard to do them wrong.The NAS report proposes a comprehensive strategy for government, industry, consumers, and healthcare providers to reduce medical errors. On Tuesday February 22, President Clinton announced a plan to implement those suggestions, with the goal of ensuring that all 50 states have mandatory reporting systems within three years.Under the Cinton proposal, all military hospitals and clinics, and the over 3000 blood banks currently in operation, would be required to report all errors. The more than 6,000 hospitals participating in the Medicare program would institute programs to reduce medical error, and establish automated systems for ordering prescription drugs, in order to avoid mistakes caused by misreading of doctors handwriting, or misunderstanding orders given by phone.The Food and Drug Administration would be required to develop new standards to prevent errors caused by drug names that sound alike and packages that look alike. In addition, new labeling standards will require drug makers to highlight dangerous drug interactions and common dosage errors.Under the plan, patients would have access to information about preventable medical errors that cause serious injuries. If a patient died as a result of a preventable error, the patient's relatives would be given that information. Patients would lose none of the rights they currently have to sue doctors and hospitals for malpractice or negligence.President Clinton endorses the National Academys goal of reducing medical errors by 50 percent over the next 5 years, and has asked Congress for $20 million to create a Center for Quality Improvement and Patient Safety, as part of the federal Agency for Health Care Research and Quality, in the Department of Health and Human Services. This body would oversee a mandatory system of medical error reporting, similar to the National Transportation and Safety Board.Why would any rational human being oppose what Mr. Clinton calls a balanced, commonsense approach, based on prevention, not punishment, based on problem-solving, not blame-placing? Apparently fear of liability is a more potent motivator than patient well being. The American Medical Association, the American Hospital Association, and other healthcare lobbies, stand in vehement opposition to any plan that would require mandatory reporting. They say that such accumulation of information would expose doctors and hospitals to more lawsuits.Since 1760, when doctors first became licensed in this country, physicians have enjoyed the luxury of policing themselves, a privilege not extended to any other profession. Peer review, a notoriously ineffective means of exposing wrongdoing, has been the sole method of discipline within the medical profession. It is the firewall behind which incompetent practitioners hide, and its high time it was breached.What would Hippocrates say? Make a habit of two things: To help, or at least to do no harm.

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