Releases Saturday 18 March 2000
No 7237 Volume 320

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(1)  "BLAME AND SHAME" CULTURE PERPETUATES
MEDICAL ERRORS

(2)  MEDICINE COULD LEARN VALUABLE LESSONS
FROM AVIATION INDUSTRY

(3)  CHANGES IN PROCESSES CAN SUBSTANTIALLY
REDUCE ERROR


Data from the US show that every few minutes, eight patients
will be injured by preventable medical errors, one of whom
will die. The likelihood that a patient will be injured by a
medical mistake in hospital is at least 3 per cent, and
probably much higher. And there are probably 10 times as
many medical errors and "near misses" as are actually
reported.

This week's theme issue of the BMJ tackles the causes,
costs "and potential remedies" of medical error, estimated to
result in up to 98 000 unnecessary deaths and 1 million
excess injuries every year in the USA alone.

A conference on reducing error in health care and improving
patient safety will be held on Tuesday 21 March at the
Institution of Mechanical Engineers, 1 Birdcage Walk,
London SW1

(1)  "BLAME AND SHAME" CULTURE PERPETUATES
MEDICAL ERRORS

(Let's talk about error)
http://www.bmj.com/cgi/content/full/320/7237/730

(Safe health care: are we up to it?)
http://www.bmj.com/cgi/content/full/320/7237/725
Lucian Leape and Donald

(Medical error: the second victim)
http://www.bmj.com/cgi/content/full/320/7237/726

As long as medicine continues to foster a "blame and shame
culture," underpinned by fear of litigation and by doctors
themselves, mistakes will keep on happening, argue several of
the editorial writers in this week's issue. Both doctors and
patients have colluded to create an impossible expectation of
perfection, they say, which makes it impossible to admit
mistakes, let alone learn from them and prevent them
happening again.

"We don't talk much about errors because deep down we
believe that individual diligence should prevent errors, and so
the very existence of error damages our professional self
image," writes James Reinertsen, chief executive of
CareGroup and Beth Israel Deaconess Medical Center,
Boston. But most errors are inbuilt in the system and "waiting
to happen," he says.

Guest editors of this week's issue, Lucian Leape, of Harvard
University's School of Public Health, and Donald Berwick,
of Boston's Institute for Healthcare Improvement, agree that
doctors have been "shackled" by a culture of blame and guilt.
This, they say, disallows safety issues the importance they
deserve - despite three decades of accumulating evidence.
They point out that not only processes but also conditions,
such as hours and workload, need to be re-examined.
Change is long overdue and must be driven by the profession
itself, they write. "Patient safety depends on an open and
non-punitive environment where information is freely shared
and responsibility broadly accepted."

Albert Wu, of the School of Hygiene and Public Health at
Johns Hopkins University, Baltimore, describes how doctors
become the second victims of their mistakes through the
subsequent isolation and fear of reprisal they suffer. "You feel
singled out and exposed"  " You agonise about what to do" You
know you should confess but dread the prospect of potential
punishment and of the patient's anger."

Contacts:

Dr James Reinertsen, chief executive officer, CareGroup and
Beth Israel Deaconess Medical Center, Boston,
Massachutsetts, USA.
Email: jreinert{at}caregroup.harvard.edu

Professor Lucian Leape, Harvard School of Public Health,
Harvard University, Boston
Email: leape{at}hsph.harvard.edu

or

Dr Donald Berwick, Institute for HealthCare Improvement
Boston.
Email: dberwick{at}ihi.org

Associate Professor Albert Wu, School of Hygiene and
Public Health and School of Medicine, Johns Hopkins
University, Baltimore, Maryland, USA.
Email: awu{at}jhsph.edu
awu{at}jhsph.edu 

(2)  MEDICINE COULD LEARN VALUABLE LESSONS
FROM AVIATION INDUSTRY

(Error, stress, and teamwork in medicine and aviation: cross
sectional surveys)
http://www.bmj.com/cgi/content/full/320/7237/745

(On error management: lessons from aviation)
http://www.bmj.com/cgi/content/full/320/7237/781

Despite their rarity, the high visibility and often equally large
death tolls of plane crashes have forced the aviation industry
to take error very seriously.

Sexton and colleagues from the Human Factors Research
Project at the University of Texas, compared attitudes about
error, stress, and teamwork among over 1000 operating and
intensive care unit staff and 30 000 airline pilots from around
the world.

Consultant surgeons were almost three times as likely as
pilots, and consultant anaesthetists almost twice as likely, to
deny the effects of fatigue on performance. Virtually all pilots
rejected the idea of steep hierarchies, in which senior team
members are not open to junior team members' input. But
only half of the surgeons did so. Only a third of staff reported
that errors were handled appropriately at their hospital. A
third of intensive care staff denied making errors at all, but
half said they found it difficult to discuss mistakes. The
authors conclude that barriers to discussing error become
even more important in the face of such levels of denial.

Acknowledging that operating theatres are rather more
complex environments than aircraft cockpits, Robert
Helmreich, from the Human Factors Research Project at the
University of Texas, nevertheless shows that the human and
systems approach to error adopted by the aviation industry
could be used as a template for medical practice. Unlike
medicine, the aviation industry has accepted the inevitability
of error, and has invested in non-punitive incident reporting
systems and safety audit. Helmreich shows how these
provide reliable data to inform training and develop models
for the management of error, which focus on human as well
as technical performance and include the work environment
and professional culture. And he suggests how they could
usefully be applied to medical practice.

Contacts:

Bryan Sexton, Human Factors Research Project, University
of Texas, USA.
Email: sexton{at}psy.utexas.edu

Professor Robert Helmreich, Department of Psychology,
University of Texas, USA
Email: helmreich{at}psy.utexas.edu
 

(3)  CHANGES IN PROCESSES CAN SUBSTANTIALLY
REDUCE ERROR

(Implementation of rules based computerised bedside
prescribing and administration: inervention study)
http://www.bmj.com/cgi/content/full/320/7237/750

(Reducing errors made by emergency physicians in
interpreting radiographs: longitudinal study)
http://www.bmj.com/cgi/content/full/320/7237/737

Two studies in this week's issue look at how changes in the
way things are done can have a significant impact on safety.

Nightingale and colleagues from the Department of Medicine
at the University of Birmingham describe a rules based
system for the prescribing and recording of drugs given to
patients. The system can be accessed from the bedside
through wireless terminals. During 11 months of monitoring,
the system prevented 58 unsafe prescriptions and gave over
700 high level warnings. Complete and legible prescriptions
have eliminated transcription errors and most of the staff on
the 64 bed renal unit, where the system was tested, felt that it
was better than handwritten prescriptions.

As Dr Reinertsen points out in his editorial, medication error
is the most common single preventable cause of injury to
patients: baggage handlers, he says, make fewer mistakes
with our luggage than do medical staff with drugs given to
patients in hospital.

In a study from the Department of Emergency Medicine at
Overlook Hospital in New Jersey, Espinosa and Nolan show
the impact of learning from mistakes, and of cooperation
between clinical disciplines. Monthly team meetings, in which
all emergency staff were involved, reviewed mistakes made in
the interpretation of x -ray pictures. An error file was set up
and used for teaching. A system was then devised for daily
use all year round in which every film was interpreted initially
by the emergency room doctor and then reviewed within 12
hours by a radiologist, as a quality control measure.

This replaced a system in which responsibility for the initial
reading varied between the emergency room doctor and the
radiologist, depending on the time of day and day of the
week. The error rate more than halved after the first
intervention and fell further when the system was
re-configured. The authors estimated that the number of
potential mistakes fell from 19 per 1000 cases to just three.

Contacts:

Dr Peter Nightingale, Wolfson Computer Laboratory,
Department of Medicine, University of Birmingham.
Email:  P.G.Nightingale{at}bham.ac.uk

Dr James Espinosa, Department of Emergency Medicine,
Overlook Hospital, Summit, New Jersey, USA.
Email: jim010{at}aol.com

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