“PRIMUM NON NOCERE”
~ Parisian pathologist and clinician Auguste François Chomel (1788-1858)
“Gross and Microscopic autopsy exam indicate probable recent acute myocardial infarct…”
~ Rapid City Regional Hospital pathologist
A winter night in 1982 found me as the physician on-call at the Pine Ridge Reservation Indian Health Service Hospital (IHS), assessing a 29-year-old patient. He and his young family had driven from a remote part of the reservation for recurrent abdominal pain. His chart notes, vital signs, and physical exam indicated a diagnosis of recurrent alcoholic gastritis. He left the hospital feeling better after a dose of antacids (proton pump inhibitors were not yet available)[1], resolving to again try alcohol avoidance, and follow-up as needed.
Four hours later, the ambulance transported him back to our hospital because his wife had been unable to awaken him. An IHS-required autopsy revealed that I had mis-diagnosed his myocardial event, with deadly results.
My patient’s death was a tragic result of unintentional error. His limited medical chart documented prior visits for seemingly identical symptoms and “diagnoses.” There had been no prior suspicions of coronary artery disease or accelerated atherosclerosis. I, and the IHS, failed him and his family in prior health visits and certainly that winter night.
Physician diagnostic and therapeutic errors have been and remain stubbornly woven into healthcare. In the past 40 years, medical errors by physicians and non-physician professionals have become a leading cause of disability and death in the United States. Approximately 400,000 hospitalized patients in the U.S. experience preventable harm each year, and the economic impact is estimated to be up to $20 billion a year. “The current state of medical error is totally unacceptable”.[2]
Recent pandemic years have pushed physicians, healthcare professionals, and hospital systems to the breaking point, further increasing health safety declines.[3] It is beyond time to address safety in our hospitals and our practice of medicine.
Patient harm typically occurs due to the convergence of any of multiple factors, including physician burnout.[4] Accurately quantifying patient safety issues is stymied by national mortality statistics’ use of exclusionary coding. International Classification of Diseases (ICD) billing codes were adopted in 1949 to tally causes of death. “At that time, it was under-recognized that diagnostic errors, medical mistakes and the absence of safety nets could result in someone’s death, and because of that, medical errors were unintentionally excluded from national health statistics.”[5] These billing codes don’t have a built-in way to recognize incidence rates of mortality due to human and system factors, i.e., “medical care gone wrong."[6]
Can our profession learn lessons of safety from other industries? Perhaps. In the past 13 years, domestic airlines have transported more than 8 billion passengers without a single crash fatality. Dr. Atul Gawande’s 2009 book “The Checklist Manifesto” borrowed the use of checklists from aviation and construction industries to reduce human failures in surgery. U.S. hospitals and our profession of medicine may lethally impact an estimated 400 patient lives each day, the equivalent of a 747 jumbo jet crashing every 24 hours.[7] Much work still remains to reduce overall medical errors.
We are trained as physicians to achieve perfection in our care for patients, yet that narrative is a trap. We cannot make every diagnosis correctly or in a timely manner. Increasing complexity in healthcare systems has created imbedded behaviors, conditions, and system circumstances influencing medical errors.
Forty years ago, there was no IHS database to report errors, nor any mechanism to analyze the root cause(s) or precursors of the event. My apology to the patient’s family did little to minimize their judgment or assuage their pain. I have never forgotten that night, that patient and family, or my feelings of profound failure. There was no state medical association available to provide collegial guidance or support. I did, however, use that experience to search for error within myself as a physician and within any practice environment to cultivate a professional path of continuous dedicated study, meticulous clinical practice, and systems’ improvement.
Your 2023 SCMA Annual Meeting will be offering insights about patient and professional safety, and much more, April 27-30, in Myrtle Beach. The President’s Session on April 29 will feature experts and commentary in medical and aviation safety (translational to healthcare), physician self-care and burnout. More details will follow in upcoming months. Until then, save the date for our 2023 Annual Meeting and as always, I welcome hearing your voice at scmayeakel@gmail.com.
References
[1] Strand DS, Kim D, Peura DA. 25 Years of Proton Pump Inhibitors: A Comprehensive Review. Gut Liver. 2017 Jan 15;11(1):27-37. [PMC free article] [PubMed]
[2] Can Hospitals Learn About Safety From Airlines? Wall Street Journal, Andy Pasztor Sept. 2, 2021
[3] https://www.nejm.org/doi/full/10.1056/NEJMp2118285
[4] Physician Burnout, Well-being, and Work Unit Safety Grades in Relationship to Reported Medical Errors - Mayo Clinic Proceedings https://www.mayoclinicproceedings.org/article/S0025-6196(18)30372-0/fulltext
[6] Moriyama, IM; Loy, RM; Robb-Smith, AHT (2011). Rosenberg, HM; Hoyert, DL (eds.). History of the Statistical Classification of Diseases and Causes of Death (PDF). Hyattsville, MD: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics. ISBN 978-0-8406-0644-0.
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