Thursday, January 24, 2013

Mistakes Matter

(Mistake 2003.)

We all make mistakes.  Some are big but turn out to be inconsequential, like when I applied to the wrong master’s program at Emory University.  Months later, the kind folks in the MPH program called to tell me that they had passed my application along to the MSPH program they thought I was better suited for and that I was accepted to both programs.  Best mistake aftermath ever.  In medicine, sometimes patients are given the wrong medication dose but suffer no ill effects.  Some small mistakes, however, have large, lasting impact (see: offspring, unplanned; see also: Lee, Joy L.).

Like you and me, healthcare workers can mess up on the job.  Some mistakes are preventable, some not.  Some harm patients, many don’t.  But their mistakes become a public health problem when preventable errors are left un-addressed and systematically harm population health. 

My father is having heart surgery next week.  I have literally watched sausage get made, and a live chicken transform into a carcass and then my lunch without losing my appetite.  But I cannot say the same of watching how healthcare is made.  As a health services researcher in training, I am very familiar with the seminal Institute of Medicine report To Err Is Human.  I know that tens of thousands of hospital deaths result from preventable medical errors each year.  That the annual economic costs of these errors amount to $17 to $29 billion.  And how these errors can shake the patients’ trust in their physicians.

The upcoming surgery makes me nervous for all the places where mistakes can happen, but in recognizing errors as a public health problem, we are also able to treat them with public health solutions.  Rather than eyeing each nurse and doctor suspiciously (bad for frown lines), I can look at the structures of the hospital.  How do these providers communicate with one another?  How do they know they're not forgetting anything?  Do they rely on messy handwriting for prescriptions?  The majority of medical errors are not caused by malicious, negligent individuals, but faulty systems.  And in fixing faulty systems, by implementing checklists (surely you have heard of checklists), automating processes, or changing organization cultures, our hospitals and providers can better focus on the important task of keeping you, me, and my dad healthy.  

This light post is the first in a few I plan to write on this public health problem.  In the coming posts, we’ll look at some specific interventions that work to improve patient safety and reduce errors.  Until then, remember to always measure twice and cut once.

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