Medical Errors Are Still A Problem

Ask physicians about mistakes, and if they are honest they’ll admit that medical errors are common, especially other people’s errors. In a recent survey in the New England Journal of Medicine more than a third of the doctors had observed an error made in the care they or a family member had received.
Despite first-hand familiarity, most doctors don’t count medical mistakes as critically important. Yet the Institute of Medicine (IOM) estimated in 1999 that nearly 100,000 Americans die in hospitals every year as a consequence of errors, many of which could be prevented.
Dr. Don Berwick, a member of the IOM investigating panel, has remarked, “Imagine what the reaction would be if we had a similar mortality in aviation.”
There would be outrage, and most people would refuse to get on a plane again. But though the crash of a jumbo jet is a major event, it is rare. The number of people killed by medical mistakes is equal to a crash every single day of the year, but it doesn’t make dramatic footage for the evening news.
If people realized how common serious mistakes can be, they might not enter a hospital or even get their prescriptions filled. A recent study from Auburn University suggests that two prescriptions out of every hundred filled in community pharmacies have errors. That amounts to 60 million mistakes each year.
Some errors are due to illegible prescriptions or sound-alike drugs. It’s understandable, though unforgivable, when a prescription for Prozac is filled with Prilosec or Fiorinal is substituted for Florinef. It is harder to comprehend how the steroid prednisone could be dispensed in place of the diabetes drug glipizide or the blood pressure medicine clonidine substituted for the hormone Premarin.
These actual mistakes occurred in part because pharmacists are overwhelmed. Busy stores are frequently understaffed and pharmacists may fill hundreds of prescriptions a day. Twelve-hour shifts are not uncommon in the pharmacy. Worse, medical residents are often expected to make life and death decisions while working 36 hours straight.
Truck drivers aren’t allowed to drive for more than 10 hours at a time and work hours for airplane pilots are also tightly regulated to avoid fatigue and the inevitable errors that accompany exhaustion.
Health professionals should take a page from the airline industry. To prevent crashes there are stringent safety rules. Before a plane ever takes off, the pilot and co-pilot must run down a check list.
In aviation, errors are reported so that they can be addressed. An airline with a nonpunitive approach to the reporting of mistakes recorded 5,000 separate incidents in less than two years.
Many experts argue that the same nonpunitive policy is needed in hospitals so that sources of human error can be studied and corrected. Currently, physicians, pharmacists and other health professionals fear reprisals or lawsuits if they admit to making a mistake.
New airport security measures are pricey but justified. It’s time for all of us to become as concerned about medical safety as we are about airline safety. Many more lives are at stake.