Fixing the Errors of Our Ways

Oops!

Not exactly the word you want to hear in the context of medical care. (Although if you want to see one of the greatest descriptions of “Oops!” out there, check out this Nov. 10, 2011 episode of “The Daily Show” featuring Jon Stewart, about Texas governor Rick Perry’s (R) blunder during the GOP debate that essentially ended his candidacy.)

But what I’m talking about is a medical error I made just the other day. In the middle of a morning schedule packed full of patients — including four patients who’d already arrived late for their appointments, and a new patient who had been squeezed into an overbook slot for which they also arrived late — I forgot about a lab test that I had wanted to order on a patient of mine that I’d finished seeing, and rushed back into my office between patients to put the lab order into the computer.

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I began typing the name of the test, and moved the cursor up onto my “favorites” list (somehow I find it distressing that I have favorites when it comes to labs and other testing — this should be reserved for flavors of ice cream, old movies, and T-shirts), and clicked on the one I wanted order — or thought I wanted to order.

Unfortunately, I had inadvertently clicked on the next one on the list, which had a similar name, or at least part of it was the same. I signed the order, and it got posted over to our phlebotomist, who printed the label and sent it off with the specimen previously drawn. The next morning, there it was in my in-basket, and I remember having a puzzled look on my face, furrowing my brows and squinting my eyes and thinking, “What?”

Why in the world had I ordered this test? Had I ordered this test? What was I thinking?

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And then I realized, I hadn’t been thinking. I had been acting reflexively, running on overdrive, scrambling and trying to keep all the balls in the air. I made this mistake because I had not been careful, I had not checked my work, and I had not done what needed to be done — which was to slow down, take a deep breath, and think about what I was doing.

We know that this is the reason behind a lot of errors — in the medical field and in so many others — when we are overworked, over-stressed, distracted, exhausted, and we understandably let the pressure get to us. We know that this is when we make errors, this is when we most need help, this is when we need to catch ourselves, to stop and say, “Let’s think again before we leap.”

Fortunately, no actual harm came to this particular patient, other than having a few extra cc’s of blood drawn, the need for a future phlebotomy session, and the inconvenience of their time. But it reminded me again how very human we all are. I called this patient and apologized, explained what had happened, told them that they would not be responsible for the cost of the accidental lab test, and said we could do the correct test during an upcoming visit.

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Medical errors have the potential to be so much worse. I could’ve ordered the wrong medicine; I could’ve ignored a test result. A surgeon could operate on the wrong body part or the wrong side. So where does the answer lie? How do we move toward a system where things like Six Sigma and Zero Harm can actually be put into place and truly function as promised?

In the middle of the past pandemic year, with everyone so overwhelmed, and the ongoing burdens of all the rest of the care we’re trying to provide, it’s not surprising that we are all burned out, stressed, and tired. This is just the kind of environment that is ripe for medical errors. The fact that some doctors and other healthcare providers lack the cognitive bandwidth and don’t have enough of a buffer to handle yet another thing being thrown at them, is a warning sign of a system that is already stressed to a near breaking point.

I don’t think the answer could possibly be in yet another system built into the electronic medical record, one more box that we need to click. Instead, we’ve got to find a way to build a kinder, gentler system that decompresses our lives so that we can focus on the care we need to provide. But if, instead, we just keep throwing more and more on doctors, nurses, and other providers, these tiny cracks in the armor are going to widen until we have a major fault line open up and things come tumbling down.

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I would not have been bothered if, at that point in my hectic morning, the computer had been smart enough to say to me, “Are you crazy, Fred? There’s no reason that we can see that this person needs Test A — maybe you mean Test B?” But over and over we’ve seen that doctors and others quickly blow by these alerts, hitting the “Enter” key with ever-increasing fury as we try to get our work done. “Leave me alone; I know what I’m doing.”

The answer may be more support, more decanting of useless work away from us, and even figuring out how to eliminate some of the unnecessary flotsam and jetsam that has built up around the healthcare system. Checklists, AI, best practices, and other built-in smart systems must be designed to improve our lives, and the lives of our patients, without adding undue burden. But the first step has to be recognizing that we’ve reached a limit, and the next has to be an answer to our cry for help.

Help!

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Fred N. Pelzman, MD, of Weill Cornell Internal Medicine Associates and weekly blogger for MedPage Today, follows what’s going on in the world of primary care medicine from the perspective of his own practice.

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