Tuesday, September 8, 2009

Swiss Cheese and Medical Errors

There's no real reason to single out medical errors from all the other types of errors in the world, except for one: they kill a lot of people. According to a leading study on the matter, about 98,000 patients in the U.S. die each year from medical mistakes.

This doesn't cause much of a public outcry, though, because most medical mistakes are buried with the patient. On the rare occasion when an error is revealed, blame is usually attached to an individual doctor or nurse (or both).

But if you want to understand why this approach to blaming individuals doesn't stop future errors from happening over and over again, read Josie's Story, which is reviewed here. The book is written by Sorrel King, whose 18-month old daughter, Josie, died from complications from treatment in 2001 at the world-famous Johns Hopkins Medical Center.

From the review:

"As Ms. King notes, the problem is often not a single doctor or nurse or misplaced decimal point on a medication vial but rather faulty systems and communication breakdowns."

Exactly. Most mistakes can be best understood by what experts on human error call the "Swiss cheese effect." Basically, errors are like the holes in slices Swiss cheese; for an error to happen, all the holes in various slices of the cheese have to line up. When they do, an error gets through.

Anyone truly interested in reducing errors in any workplace -- whether it's an operating room or a factory floor -- should take note.

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Blogger Davis Liu, MD said...

Thanks for a great book (and this post). Healthcare can learn more from highly reliable organizations (you note the stark difference between naval aviators compared to surgeons on the systems and culture of safety) to make our patients safer.

What I find particularly interesting about this post is that Ms. King, Peter Pronovost, an intensivist at John Hopkins, and myself are compelled to write and speak about how much more healthcare must improve because each of us have had a bad outcome occur.

I hope doctors read your book just to simply understand how our innate wiring sets us up for failure and we must develop systems and a culture to protect our patients from our too human failings.

Davis Liu, MD
Author of Stay Healthy, Live Longer, Spend Wisely: Making Intelligent Choices in America's Healthcare System
Website: www.davisliumd.com
Blog: www.davisliumd.blogspot.com
Twitter: davisliumd

February 23, 2010 at 7:05 PM  
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