As you may have figured out by now I follow information about the health care industry pretty closely. As a hospital CEO for seventeen years, the New York Times, Newark Star Ledger and Jersey Journal were on my desk every morning when I walked in the door. Then as an adjunct professor in two graduate programs, and with the instantaneity of the internet, I got about a half a dozen news updates and summaries immediately, daily and weekly. But even with this constant immersion, sometimes articles are so compelling that I have to stop and think about the implications. This happened recently.
I was startled (and reminded) by a New York Times article “Medical Errors May Cause Over 250,000 Deaths a Year” which noted: “If medical error were considered a disease, a new study has found, it would be the third leading cause of death in the United States, behind only heart disease and cancer.
“Medical error is not reported as a cause of death on death certificates, and the Centers for Disease Control and Prevention has no “medical error” category in its annual report on deaths and mortality. But in this study, researchers defined medical error as any health care intervention that causes a preventable death.
For example, in one case a poorly performed diagnostic test caused a liver injury that led to cardiac arrest, but the cause of death was listed as cardiovascular. In fact, the cause was a medical error. Diagnostic errors, communication breakdowns, the failure to do necessary tests, medication dosage errors and other improper procedures were all considered medical errors in the study.” (A)
Soon after a Washington Post article “Exclusive: Patient safety issues prompt leadership shake-up at NIH hospital,” noted: “The National Institutes of Health is overhauling the leadership of its flagship hospital after an independent review concluded that patient safety had become “subservient to research demands” on the agency’s sprawling Bethesda campus.
The shake-up at the NIH Clinical Center, which was announced to staff Tuesday, represents the most significant restructuring at the nation’s premier biomedical research institution in more than half a century.
NIH Director Francis Collins said he will replace the hospital’s longtime leadership with a new management team with experience in oversight and patient safety, similar to the top structure of most hospitals….” (B)
These articles sent me looking for a 2007 classic book – “How Doctors Think” (C) by Dr. Jerome Groopman, Chairman of Medicine at Harvard Medical School.
Discussing actual cases from his own clinical practice, Dr. Groopman developed a classification system for medical mistakes, observing a tendency to treat a case based on past experience rather than looking at it based solely on the evidence.
“Vertical Line Failure – thinking inside the box
Confirmation Bias – confirming what you expect to find by selectively accepting or ignoring information
Anchoring –the failure to consider multiple possibilities but quickly and firmly latching on a single one
Availability –an unusual event that recently occurred which has similarities to the current case causing MD to ignore important differences
Commission Bias – tendency toward action rather than inaction due to “bravado”, desperation, or patient pressure
Relying on “Strict Logic” – answering a clinical question in the absence of empirical data
Over-reliance on Clinical Algorithms – simply filling in the blanks on the template
Haste – complicated problems cannot be solved quickly
Outcome Bias – thinking that the diagnosis that is wished for has occurred• Limited Searching –stop searching for a diagnosis once “
This is not to criticize physicians who get most things right and in a very challenging, fast-moving environment occasionally make mistakes.
The point is we all fall into comfortable patterns of thinking – our own default classification systems.