In her New York Times health care blog post of August 4, 2011, entitled A Better Way to Keep Patients Safe, Dr. Pauline Chen writes about the consternation that met the lack of improvement in the number of deaths due to medical errors in the decade since the publication of To Err is Human. That book, by the Institute of Medicine, disclosed the high incidence of fatal medical errors in U.S. hospitals. The supporting article in the New England Journal of Medicine that Dr. Chen cites was based on studies in North Carolina, a state that had a reputation for following all the right procedures to make health care delivery systems safer. Those procedures make up the so-called systems method of medical error reduction. The study she quoted was published at the same time as a separate report by the Inspector General of HHS which showed similar results in another group of patients, enrollees in Medicare.
As a hospital chief of staff for five years, I look upon systems correction methods as default strategies. A greater problem than faulty systems is faulty doctors. There is substantial data to support my contention. It comes from the Harvard Medical Practice Studies which were based on a meticulous review of 30,000 hospital charts, a set of observations that have not been repeated on that scale and have not been surpassed in scientific quality. To Err is Human turned that data on its head and concluded that bad systems were the problem.
The Harvard Studies had one critical table that classified all the causes of bad outcomes. Technical errors and picking the wrong diagnostic tests caused most of the adverse events. Those things are the products of a doctor’s mind and hands and can only be attributed to errors by individual practitioners. The most reasonable conclusion is that the doctors were causing most of the errors. The systems experts insisted that disciplining bad doctors was irrelevant to improving patient safety. The state boards of medicine, which license and discipline doctors, bought into their thinking and made a proclamation in 2008 that many of the doctors reported to them should be considered the victims of flawed medical care delivery systems since most of the errors that harmed patients were of the systems variety. In fact, the Harvard studies said that only 6% of patients were harmed by such errors.
As a hospital chief of staff I saw a hard core of several doctors who bungled things regularly while the majority of their colleagues got things right working with the same delivery systems. In addition, it was that group that persistently flouted precautions such as time outs, hand washing and clinical guidelines that the systems experts tout. This is not a mere splitting of academic hairs. 1.2 million lives in the next decade are at stake. It could take at least another generation to get this right if we persist with the present narrow, questionable approach.