After two weeks of fearful medical news, Texas got some relief today. A sheriff’s deputy tested negative for Ebola. And no one else is showing symptoms.
That gives doctors and medical officials a little breathing room and a chance to look back at what might have gone wrong in the case of Thomas Eric Duncan.
In particular, why he was released hours after his first visit to the ER.
Accidents happen, and hospitals are no exception.
“[Emergency departments] are busy chaotic places, and when you do get information, there’s a lot of it,” says Dr. Albert Wu. Wu is Professor of Health Policy and Management at the Johns Hopkins School of Public Health.
Not long ago, Wu made a mistake. He prescribed an antibiotic to a patient that she was allergic to.
“The information was written in the chart,” he says, “but I did not have that immediately available to me.”
She didn’t die, but she did get a rash. While no one likes to hear about mistakes in medicine, they happen all the time.
In a study looking at at eight hospitals, researchers found nearly nine teamwork errors occurred per patient case, and fifty percent of the harm that occurred could have been avoided.
Why? Humans, circumstances, and systems.
What Lies Beneath The Error
Dr. Brian Goldman says good, well-trained, ethically grounded medical professionals are making mistakes every day.
“They just don’t know it because we’re not curious.”
Goldman is curious about mistakes. He’s an emergency room physician at Mount Sinai Hospital in Toronto and a medical journalist who hosts the show White Coat, Black Art.
He says in medicine, the knee jerk reaction is to find someone to blame, because that means nothing is wrong with the system.
Just look at what happened with Texas Health Presbyterian in Dallas.
“So in the first case it was a nurse who didn’t transmit the information, then the electronic health record, […] now it’s a physician,” he says. “I understand that the root causes of medical errors, is there are usually a litany of factors that contributed.”
The Swiss Cheese Model
Here’s where the Swiss cheese model of mistakes comes in. At each decision point, Goldman says, from the first encounter by the triage nurse, to the note scribbled by a physician, each small decision is like a slice of Swiss cheese – there may be holes, but a tiny gap in flavor won’t be a problem.
But there’s catastrophe when the holes in the Swiss cheese all line up.
Electronic health records can help with checks and balances in a hospital.
For example, if a nurse enters in the words nausea and temperature in an electronic note, a prompt to ask about recent travel history might pop up.
“I think that we have a lot of room for improved team-based care using electronic health records than we ever had with the paper world,” says Dr. Sarah Corley.
Corley is Chief Medical Officer at NextGen Health Systems – it provides electronic medical records for about 14,000 health care providers in Texas.
Doctors Are Humans
Hospitals across the country are betting technology will improve patient safety. But the executive commissioner Texas Health and Human Services Dr. Kyle Janek has this sober reminder.
“The processes that we use are implemented by human beings. We can automate a lot of things, we can make computers pop up certain notices. But at the end of the day, the backbone of this system relies on human beings.”
And human beings make mistakes.
“Probably one of the worst mistakes I’ve made as a physician, Goldman says, “was sending a patient home when I was a trainee.”
“This was a patient who had congestive heart failure, I treated her appropriately and she was feeling better, and then I sent her home when I should have run the story by my attending.”
She collapsed several hours later, was sent back to the hospital, and died a week later.
It was horrible for her family, Goldman says, and horrible for him.
A Second Victim
Dr. Wu at Johns Hopkins says when a mistake happens in medicine there are multiple victims.
“A second victim is a health care worker who is also traumatized by a bad outcome that a patient experiences.”
Assigning blame, ignoring the problem, these are typical coping routines in health care.
Instead, Goldman says it’s time to get curious. Don’t run from the mistake, run toward it.