Progress in patient safety can only come from the slow work of science and the honesty of our limitations
During To Err is Human, a new documentary about medical errors currently on tour throughout the United States, former Medicare chief Don Berwick claims that ending medical error is simply “a question of will.” This assured premise is echoed throughout the film by turns urgent and optimistic. Another expert makes the astonishing claim that “we can drive [medical errors] to zero.” Impressive, given the outsized estimates of harm in the film, which suggests up to 440,000 people die from medical error in the US each year, making it the third leading cause of death. But is the right mindset really all we need to prevent medical errors?
As I’ve progressed in my medical training, I’ve wondered why I’ve grown less comfortable with the patient safety movement. Watching To Err is Human, the sentiment crystalized: instead of being engaged scientifically or humanely as a physician, “safety” often feels like a sales pitch. No doctor would passively accept the words of a pharmaceutical industry representative describing a new drug that’s perfectly effective, without side effects, and eminently affordable. Yet doctors today are expected to absorb the claims of “patient safety experts” or be branded reckless cowboys.
The film interviews some of the movement’s biggest advocates: Don Berwick, Ashish Jha, Bob Wachter, and Lucian Leape. These are charming, erudite spokespeople. The film alternates between these experts and the Sheridans, a family of victims turned activists who have been irrevocably harmed by medical errors in their son Cal and late husband Patrick. Despite lavish visual and auditory drama, the Sheridans’ truth is the film’s most convincing device, a rare human moment.
The expert portions of the film couldn’t be less humane. They tell us that to end the epidemic of iatrogenic harm, simply transfer the lessons learned from the more technical airline and nuclear power industries. Specific solutions turn out to be few and hard to pin down. Checklists and central line protocols are trotted out, in this film and elsewhere. It’s hard to believe checklists are a penicillin for the ailing healthcare system—a single shot to wipe out all its disease. The remainder of the film’s recommendations fall back on a vague “culture of patient safety”, a reluctant recognition that many of medicine’s problems are chronic and entrenched.
What exactly does a “culture of patient safety” mean? To Err is Human first suggests we need an appreciation of the scale of problem, an acceptance of an epidemic “hiding in plain sight.” Second, we must shift away from the habit of blame to address systemic deficiencies.
Medical errors are undoubtedly real and all too common, but it’s clear marketing takes precedence over reality when it comes to measuring them. The idea that 440,000 people in the US die from preventable medical error—meaning more than half of all hospital deaths or as many people as die from tobacco—is both absurd on its face and has been resoundingly debunked in the literature. [1,2] Yet these statistics frame the documentary, beginning with an escalating death counter ticking ominously upward and closing with scores of metaphorical airplanes crashing, a favorite rhetorical tactic despite the fact that you can cancel a risky flight, but rarely a patient’s hospital admission.
The patient safety establishment’s core message is sound: many errors in medicine derive from flaws in the system rather than in individuals, and thus blame should be supplanted by higher-order change. Yet at least in America it can leave doctors in just one more untenable situation. As we work under heavy legal and regulatory scrutiny, the threat of a malpractice lawsuit (or worse as shown by the Bawa-Garba case in the UK) is ever present.
The film and director counter by suggesting that doctors who admit mistakes and speak honestly face fewer lawsuits. Even if this were true—and there is evidence showing the opposite—it is little consolation as it applies to populations, not individuals. This recommendation seems like another tradeoff-free solution from the patient safety movement. Malpractice claims can feel like an existential threat to a physician, so to truly remove a culture of blame legal reforms will be needed first. Instead, doctors rather than lawyers are asked to change.
Ultimately, To Err is Human feels like superficial marketing for established advocates in the patient safety movement, each with solutions to sell us. There is real science going on in healthcare safety and quality, but like all science it is incremental, beset by detours and failures.[3]
The film refuses to acknowledge such realities. I didn’t once hear the words “tradeoff”, “downside”, or “unintended consequences.” I asked director Mike Eisenberg what tradeoffs might occur if the solutions that patient safety advocates propose take effect. To his credit, he described electronic medical records as an example of the way new technologies and “solutions” can increase complexity, paradoxically introducing error.
Of all the frightening images presented that evening—crashing planes raining from the sky, acres of graveyards eclipsing Arlington cemetery—Eisenberg’s extemporaneous allusion to electronic medical records was the most indelible. I once called these software systems “brutalist medicine” for how poorly they integrate into physician culture, creating inhumane—even dangerous—complexity in their drive toward compliance. [4] A checklist may be simple; dozens of checklists are anything but. To paraphrase George Orwell, “patient safety” sometimes means the boot of an electronic medical record or automated alarm stamping on a doctor’s face forever.
We do not want to be defeated before we even begin. Remarkable progress in safety can be made through systemic and cultural change. Like most of medicine, however, progress doesn’t arise from a crusade or a sales pitch but from the slow work of science and the honesty of our limitations.
Benjamin Mazer is a resident in the pathology at Yale-New Haven Hospital. His views are his own, and don’t represent those of his employer. Twitter @BenMazer
Competing interests: None declared.
References:
[1] Shojania KG, Dixon-Woods M. Estimating deaths due to medical error: the ongoing controversy and why it matters. BMJ Qual Saf. 2017 May 1;26(5):423-8.
[2] Gianoli GJ. Medical Error Epidemic Hysteria. The American journal of medicine. 2016 Dec 1;129(12):1239-40.
[3] Dixon-Woods M, Martin GP. Does quality improvement improve quality? Future Hospital Journal. 2016 Oct 1;3(3):191-4.
[4] Mazer B. Brutalist medicine: a reflection on the architecture of healthcare. BMJ. 2017 Dec 11;359:j5676.