to err is human

Monday, June 30, 2014

Sometime mistakes come back to bite you and sometimes they don’t. World Cup has become must see TV, even if the match is between two countries most people would not be able to find on a map. But there are three teams on the field, if one counts the referees and while they qualify for the assignment just as much as the teams they officiate, the referees don’t get much love. While the game happens at real word speed, their work is dissected frame by frame in high definition slow motion replay and their missed calls can make or break a match. In the Greece-Costa Rica match a hand ball was missed that could have allowed a penalty kick for Costa Rica and a potential 2-0 lead. At the final whistle, Costa Rica still won the game but in not without the drama of a shootout after an overtime tie.

Medicine is not without its misses. Every patient encounter, from a doctor taking a history and performing a physical examination or interpreting a test, to a nurse injecting a medication, every interaction between a patient and a health care provider can yield an error. The mistake may have huge consequences or not even be recognized and found only at quality assurance review. While the goal is always to make medical care mistake free, the reality is that there is an “acceptable” miss rate in caring for patients.

Radiology is a prime example about why medicine fails perfection. How can an acceptable miss rate for a board certified radiologist be 3%? For residents in training that number climbs to 8% or higher. It has to do with systems and not being able to touch the patient. When a patient sees a doctor and an imaging test is ordered, (an x-ray, ultrasound, CT or MRI), the radiologist does not get much background information. With today’s technology, there is no film to touch and digital images are sent through the internet tubes to be interpreted, perhaps a continent away to be interpreted. Misses don’t necessarily mean that malpractice has occurred and there may be no consequence to the patient. The error might be an incidental finding or it might be a big deal.

Other areas of medicine are ripe for mistake as well. We know that long shifts, sleep deprivation, stressful environments and large patient loads lead to increased risk for error. For that reason, house staff, interns and residents who look after patients in hospitals, have had their work hours adjusted to provide more time away from work. That change has significantly decreased the error rate in diagnosis and treatment but it also increased the number of patient handoffs, increasing that potential for error. While the patient may be in hospital for days on end, the doctors and nurses responsible for their care change two or three times a day. The handoff from one shift to another may fully explain the situation and critical information or planning can be lost. Hospitals have systems to standardize the information transfer but in the end, medical care happens at the bedside and it’s tough to explain the whole situation of patient subtleties and provider gestalt.

And sometimes, too much information to minimize error can lead doctors astray and cause damage to the patient. Just as replay can stop the flow and grind a football or basketball game to a halt, increasing the tech of testing, can potentially yield false positive and false negatives that can damage a patient. For example, if a doctor is worried about appendicitis in and orders a CT scan to help make the diagnosis, the timing must be right. If the CT is done too early and the body’s immune system hasn’t had a chance to develop inflammation, the scan may be read as normal, even if there is an early case of appendicitis…a false negative.

False positive tests may lead the patient down an unwanted road. 3D breast mammography has become the latest tool to look for small cancers. It may be the next best thing but…the test may be so sensitive that it finds lumps so small that may not cause any danger for the patient in their lifetime. Research continues but the test has already been made available.

As long human judgment is involved in medicine, the risk for mistake exists; it will never be zero though that is an admirable goal. The same situation exists is sport. Technology can decrease the human error rate but at the expense of the game.

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