An Engineer Comments On Medical Errors

In 1999 the Institute Of Medicine (IOM) issued a startling report about medical errors.  It reported some 98,000 deaths annually and one observer compared it to a 747 wide-body jet crashing every day.  Having gotten interested in this, I have kept some notes.  A new study reported in the Wall Street Journal on July 27, 2004 reported double that many deaths from medical error.  Also, antibiotic-resistant strains of bacteria are on the increase, due mainly to the over-prescription of unneeded antibiotics.  I just read of a brand-new one yesterday.

Update:  (Ref:  USA Today, May 5, 2010, p. 5D) – Doctors trying to reduce radiation risk . . .   Excerpt:  “Medical radiation from exams such as CT’s . .. causes 29,000 new cancers a year, a report in the Archives of Internal Medicine showed in December (2009). ”  This is described as a “very serious issue” and goes on to point out the particular vulnerability of children and the increased use of radiation to diagnose heart problems.  Women are for obvious reasons more vulnerable to the latter use.  The article details how shielding and synchronization of the radiation to heart cycles can drastically reduce the exposure of breast tissue to the radiation.  The FDA is studying the problem.  You decide if you want to wait for the bureaucratic solution.  PS, from personal experience and reading I know that the thyroid gland (in the throat) is vulnerable to radiation.  This too can be shielded easily, on request, from radiation when getting dental or chest x-rays.  Do not count on the “system” to protect you.

Update:  (Ref:  Parade Magazine, May 23, 2010, p. 19) — Of the different types of scans, “Abdominal, pelvis, and head scans were found to have the most radiation.  (An abdominal scan has about the same dose of radiation as 400 chest X-rays.) . . . If . . . your situation isn’t life-threatening, ask if an alternative test is possible.”

Update :  (Ref:  USA Today, online, April 13, 2010) WASHINGTON (AP) — The nation’s hospitals are failing to protect patients from potentially fatal infections despite years of prevention campaigns, the government said Tuesday.  The Health and Human Services department’s 2009 quality report to Congress found “very little progress” on eliminating hospital-acquired infections and called for “urgent attention” to address the shortcomings — first brought to light a decade ago.  Of five major types of serious hospital-related infections, rates of illnesses increased for three, one showed no progress, and one showed a decline.  As many as 98,000 people a year die from medical errors, and preventable infections — along with medication mixups — are a significant part of the problem. End Update.

Update, 4/16/10.  From Consumer’s Union via e-mail:  “More than 30,000 Americans die every year from bloodstream infections they get from catheters while in the hospital.  And just this week, federal researchers reported that rate is rising.  But a leading Johns Hopkins doctor has developed a simple checklist that when used, could cut these types of infections by two-thirds.  Some hospitals have even eliminated these kinds of infections for periods of time using the checklist.  These bloodstream infections are one of the most common — and preventable– deadly infections in hospitals.  And they add an average of $42,000 to the hospital bills of each ICU patient.  Sensing there had to be a better way, Dr. Peter Pronovost, a critical care specialist and patient-safety researcher at johns Hopkins School of Medicine, developed a five-step checklist to prevent them.  When the checklist was implemented in Michigan, central-line bloodstream infections dropped by 66 percent, and an estimated 1,500 lives and $200 million were saved in the first 18 months.”  Does YOUR hospital use this checklist?

I believe that these problems are solvable.

I am an engineer and was a submariner in my first career.  I also have a Master of Science in Administration (Management Engineering) degree, so while I am by no means a medical professional I do feel comfortable with management and technology  and at age 73 I am also nearing the end of a course in the college of hard knocks.  (Sensing my body’s signs of wear has added to my incentive for this project.)

How are Joplin’s two hospitals coping with medical errors? I will post some questions and I ask any readers, particularly any who have recently had medical care locally, to respond to them.  Please also feel free to pose new questions.  If your experience is with Freeman Health Systems or St. John’s Regional Medical Center, please be specific.  I would like to know if one is doing better than the other.  OK, here goes, in no particular order:

  • Does your doctor wear neckties between seeing patients? Doctor’s neckties typically harbor germs and carry them from patient to patient.  Does your hospital have a policy on wearing them?
  • When you are in the hospital and your doctor examines you on his rounds, does your doctor wash his hands first? This is a proven method of spreading pathogens from patient to patient.
  • When you are scheduled for an operation, will your doctor and his team use a check-list to ensure correct procedures and equipment? I ask this not only because of the occasional amputation of the wrong limb, but also losing sponges or other items inside the patient or not having the right medication or equipment on hand should the unexpected happen.  Check lists can also be used to ensure that the full operating team is actually assembled and is qualified for their positions.  All of this may seem routine and unnecessary to a surgeon who may have done a given operation successfully many times, but as a submariner I can tell you that check-lists save lives.  For example, every time a submarine first dives after coming out of port an accountable professional uses a check list to verify the position of every essential valve and switch.  Use of the list is mandatory, no matter how many times he has checked the items before.  There are also check-lists for many other complex procedures and emergencies where errors can have a heavy cost.  This lesson was learned the hard way.  Although the early history of submarines is replete with accidents and death and Russian subs in particular have suffered numerous calamities, no U. S. submarine has been lost since 1968 nor has there been a single serious radiation leak in the nuclear-powered fleet since its inception.  There can be no doubt that this sterling record is due to more than just training.  It is a systems approach based on a culture of safety.  Is it possible that medicine can learn from this example?
  • Does your hospital have facilities for “Therapeutic Hypothermia”? Doctors at the University of Pennsylvania Dept. of Emergency Medicine have been using this technology successfully since 2006 and call it “. . . one of the most promising interventions for the treatment of cardiac arrest over the past 50 years.”  One patient went into cardiac arrest and was “dead” for 43 minutes.  She recovered completely with this relatively-inexpensive technology.  Ref:  USA Today, March 29, 2010, p. 4D.
  • Do your doctor or your hospital plan to adopt electronic records?  If so, when? Yes, I know there is a federal initiative to promote this, but I am also aware that it is long overdue.  Proper software can prevent handwriting errors and confusion of similar-sounding names of medicines.  It can be programmed to flag decimal-point errors in dosages, for example.  I just read of one such error last week that had horrendous consequences.  Such software can also neatly summarize and instantly transmit patient history and test results.  Too expensive to implement?  Let’s just say that one of our two hospitals has it and one doesn’t.  I know which one I want to go to.  How about you?

About Jim Wheeler

U. S. Naval Academy, BS, Engineering, 1959; Naval line officer and submariner, 1959 -1981, Commander, USN; The George Washington U., MSA, Management Eng.; Aerospace Engineer, 1981-1999; Resident Gadfly, 1999 - present. Political affiliation: Democratic.
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