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.

Shot in the Arm

Though I only spoke Mandarin Chinese growing up, I found it cathartic, whenever I was angry, to curse in strings of expletives in Mandarin, Taiwanese and English under my breath.  But at the age of 10, I gave it all up.  It’s the only resolution I’ve kept 96% successfully for so long, to the point that when I do swear aloud now (usually to quote someone), it sounds stilted and unnatural.  I usually liken my loyalty to flu shots to my non-swearing habit: I get why you’re not like me.  No judgment here.  (Exceptions being doctors, elderly people, and others high-risk folks: the benefits outweigh costs for them and they should almost always get vaccinated). 

Our decisions to engage in protective actions like buckling up and buying insurance depend on the costs and likelihoods of the harm we want to avoid.  For many, their flu shot consideration (however brief) is something like this: 

Effectiveness x Cost of flu shot (pain, time, copay, etc.) > Risk x Cost of flu (medical expenses, lost wages, etc.)

Simply put, people choose not to vaccinate when cost > benefit.  Though getting the flu is miserable, costly, and leads to tens of thousands of deaths annually, it’s usually unlikely to touch healthy, attractive people like you.  However, the flu season is the worst in at least a decade.  Hospitals in Boston were so overwhelmed by influenza patients (more so than during the H1N1 outbreak) that the mayor declared a public health emergency.  The flu is now widespread throughout the US.  For those following the math, the risk of getting the flu is much higher than usual.  If you haven't gotten a shot: it's time to rethink your equation*.  

(The intensity this year surpasses the previous peak from H1N1.  
Click on the map to play with the google trends yourself.)

Of course, the risk of flu isn’t the only part of the equation that changes.  The cost of vaccination can be lowered to make shots more attractive.  Public Health likes that since the more people are vaccinated, the less likely it is for anyone to get the flu.  This is why flu shots are fully covered by many insurers, why employers set up workplace clinics, and why retail pharmacies don’t require appointments.   At Bowdoin College, the health center further sweetened the deal by giving Halloween goody bags with candies and toys, forever changing my attitude toward flu shots.  Whatever incentive works for you, the risk of flu is high this year and the cost of vaccination is low.  So for f*ck’s sake: get a flu shot.

*There is so much straightforward information on flu shots out there that I don't need to argue it here; the shot is effective and will not give you the flu.

Policy Implications:  Though the public benefit of flu shots is greater than that for individuals, incentives can spur individuals toward disease prevention.

Le Head Strong

The last time I was on a bike, I did not wear a helmet.  Neither did anyone around me.  I was in Seoul, Korea, visiting friends (3 public health masters on 1 trip).  We rented bikes and rode on an easy path along the river.  There were families walking, skating, and riding all around us.  Afterward, we had a fried chicken picnic delivered to us at the park (people of Korea, outdoor chicken delivery is genius).  Then wandered around a night market where I bought Che Guevara socks.  The day was so perfect that I didn’t even realize my helmet oversight until I was looking at pictures the next day.  Whereupon I immediately confessed my transgression to DHem via email*.  

(Photo Credit: Esther Kim/Alex de Rubira via facebook)

 In this past Sunday’s Times opinion pages, Elizabeth Rosenthal makes the case for repealing helmet laws to encourage biking.  Rosenthal uses the example of European cities where biking is prevalent and helmet laws rare to argue that helmet laws discourage people from riding bikes and the health benefits of riding far outweigh those of helmet wearing.  Mayor Michael Bloomberg is noted as rejecting calls for a mandatory helmet law when New York’s bike share program rolls out next year. 

Despite my idyllic Seoul ride, Rosenthal’s piece misses the point.  As our bikers noted last month, the type of safe, biker-only, slow-speed riding environment I encountered (and Rosenthal alludes to) is rare in the US.  Bikers, especially commuters, ride at high speeds among cars.  The 20-to-1 cost-benefit analysis Rosenthal touts depends on 2 assumptions that aren’t readily met in much of the US: safe riding environments and the belief that people view biking as a mode of commuting rather than exercise (and thus will not make up for not biking with other exercise).  Bike accidents may be rare events, but riding with a helmet is always safer than riding without one.

Rather than repeal helmet laws, there are better solutions using principles this blog has covered (like looking for ways of reducing the ‘cost’ of helmets and barriers to use through helmet giveaways, making rentals available, and creating biker-only lanes).  Rosenthal also missed an opportunity to push for changing the riding culture in the US the way we have with cigarette smoking.  Though warning labels may be larger in Europe, the US has been more successful at transforming perceptions of smoking and lowering cigarette use.  The US is raising up generations of non-smokers (the recent college bans in the news being one indicator of this success) who grow up in smoke-free environments and we can aim for the same for bike safety.

Policy Implication:  Making bikers safer begins with improving the riding environment, not repealing helmet laws.

*One of these days, I will stop mentioning DHem and/or bike safety in every post.  Just not today.