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Mending the Error of Our Ways

Just the other day, I made a medical error.

During a busy morning practice session, about halfway through a long list of patients, I was finishing up an annual preventive medicine visit for an elderly gentleman I’ve taken care of for many years, who has a bunch of medical problems, as well as a number of new symptoms that we addressed that day.

After we’d wrapped up, and we’d gone over the plan for all the things we talked about during the visit, as he was heading for the lab he looked back and said to me, “Doc, can I get the pneumonia vaccine today?”

In a hurry, trying to remember the labs he needed ordered and the referrals that needed to be entered into the EHR, already starting to think about my next patient, and while still in motion heading back to my office to put all these orders in the computer, offhandedly I said, “Haven’t you had that already?”

“No, I never had a pneumonia shot,” he replied.

Back to my office, I placed the order for his appropriate labs, a couple of referrals to subspecialists, and slapped on an order for a pneumonia vaccine. A little while later, as I darted between one exam room and another, our nurse grabbed me and said, “You ordered a pneumonia vaccine on this patient, but he got one about 5 years ago; did you want to give him another one?”

Puzzled, I stopped, took a deep breath, and went back to the computer where, sure enough, under his immunization records, was the notation that I’d given him his pneumonia vaccine just a few years ago, at age 72. I told the nurse he didn’t need another one, and asked her to explain to the patient that he was, in fact up to date on both versions of the pneumonia vaccine, his shingles vaccines, and his tetanus/diphtheria/pertussis booster, and since he had already received the flu shot for this year, he didn’t really need any vaccines at all today.

It Happens to All of Us

This reminds me of an old joke. The patient goes to see a doctor and says, “I want to get castrated.” Since that was a somewhat unusual request, the doctor says to the patient, “Are you sure?” To which the patient replies, “Absolutely. I’ve made up my mind; this is the right thing to do.”

So the patient is taken to the operating room, undergoes a successful surgical castration, and then is wheeled to recovery room to let the effects of anesthesia wear off. As he comes out from the fog of anesthesia, he turns to the patient lying in the next bed, and says, “What are you in here for?” That patient says, “I had a circumcision.” Our patient slaps his forehead and says, “That’s the word I was looking for!”

Errors occur for any one (or more) of a thousand reasons, during the course of our day, just as they occur in every other setting outside of healthcare, and in fact in every interaction between humans and the things we are trying to get done.

In a recent quality and patient safety meeting, we heard about an incredibly cool system being used in the in-vitro fertilization lab at our institution. As you can imagine, it’s really important during in-vitro fertilization that the right sperm go with the right egg. Our lab has adopted a system whereby each of these specimens that belong to a couple planning in-vitro fertilization are labeled with electronic tags that completely prevent two specimens from being combined that are not supposed to be mixed together.

While this sounds like a great system, more than likely, no matter what, this is only the end of a process, another fix, and there may always be upstream things that happen that prevent this from being the perfect solution we had in mind.

No System Is Perfect

Take, for example, a situation that happened at our practice just a few weeks ago.

A patient of mine had scheduled an appointment for late in the afternoon, and his wife had one for the very beginning of the practice session. At the last minute, she had something she had to do at work, so they decided to swap their appointments — he would use her 1:00 slot, and she would take his 4:30 time. So he arrived at the office, and told the front desk staff he was here to see me, to take his wife’s appointment time.

Somehow, amidst the busy crush at the beginning of the afternoon practice session, the staff went to the schedule, saw “her” 1:00 appointment, checked “her” in, registered “her”, and printed out “her” ID band, which they proceeded to affix to his wrist. At this and multiple other steps to the registration, from check-in to the vitals process, members of the healthcare team are supposed to confirm that he is who he says he is, and that the ID band he is wearing matches that information. But by the time he got into my exam room, he was still wearing his wife’s ID band, and only then did I uncover this comedy of errors.

Luckily, being a primary care doctor, I was unlikely to be performing any operation on him that was meant for her, but conceivably he could have ended up getting a vaccine that was ordered for her, or labs drawn under her name, if things had not gone exactly right.

Continuous Improvement Needed

This reminds me of another story, about a patient of mine admitted to the hospital for a limb amputation. I went to see her the night before, and she was understandably worried, took my hand and said, “Dr. Pelzman, please make sure they take off the right leg!”

“No,” I told her, “you need to make sure you say, ‘Make sure they take the correct leg,'” because it was in fact her left leg that was due to be amputated. We are all so busy, and so overwhelmed, and the processes are so complex and so contorted that it’s no surprise that, despite all our best intentions, the sponge counts are not always accurate, the correct side is not always labeled, or someone gets someone else’s vaccine or medication. This is what happens when humans interact with systems, when we’re all stressed and distressed, when things are coming at us from every different direction, and nobody’s perfect. As the saying attributed to management pioneer W. Edwards Deming goes, every system is perfectly designed to achieve the results it gets.

We can remind everybody every morning to make sure they do their job right, to make sure they check the name and date of birth and medical record number, before they do whatever it is they are doing. Even with our best intentions, we still need to make sure that we have systems in place, checks and balances, that make sure we do no harm. Because we’re all going to be asked to do things as we run down the hallway, when someone comes to our door and says, “Do me a favor — can you order labs on this patient that just walked in and needs to get out of here quickly?” when we accidentally have too many open charts on our computer, and we enter orders for the wrong patient.

The process of keeping this stuff straight is exhausting, and one would hope that in the end, everyone involved assumes a measure of responsibility, including the patient, to make sure they’re not getting a CT scan that’s recommended for someone else, or an operation on a body part they desperately want to keep. I’m not sure if the answer is more rules, more electronic checks, or machine learning and artificial intelligence that’ll run in the background to make sure we’re not making an error. But I’m quite sure that the pressure that has built up inside the healthcare system to get things done, to hurry up and fix it, to give everybody what they want, will only lead to more errors that we never meant to make.

It’s nobody’s fault but our own. But we can make it better.

Last Updated January 17, 2020