The pandemic of medical errors

Salvador Casado

George Ștefănescu - Cosmos, 1992

The death of a young person from undiagnosed cancer often comes as a shock to those around them. In recent weeks there has been a lot of controversy on social networks following the death of the journalist Olatz Vazquez, who documented her illness to the end with photos, which has encouraged me to reflect on medical error, to be self-critical of my own and to try to make proposals from a broad vision that includes all the actors. The Sarscov2 pandemic has caused another pandemic of unavoidable medical errors both by action and, above all, by omission, because the collapse of health systems around the world has caused them to stop attending sufficiently to other pathologies for many months. In the following text I approach the subject from the point of view of a healthcare professional who tries to explain it to his patients and colleagues and not from a technical approach, for which I provide a list of suggestions for further reading at the end.

We will start with the following premises:

1. Doctors make mistakes.
2. They terrify us, they are very painful for the one who suffers them and for the one who commits them, and they can produce after-effects in both.
3. There is no way to eliminate them completely.
4. They affect all health professionals at all levels of health care and in all countries.
5. Every user of medical services is susceptible to them, the greater the use, the greater the possibility.
6. Society's current use of healthcare is intensive, so it is foreseeable that this problem will increase.

The question we should all be asking ourselves is: How can we reduce it? I propose five answers:

1. With well-designed and well-managed healthcare systems.
2. With well-trained, motivated and not burnt out health professionals.
3. With a citizenry that knows how to use the health system well.
4. With health managers and politicians who look after the common interest and care for the viability of the system.
5. With evaluation, quality and safety systems.

With well-designed and well-managed health systems

1. Primary care systems where the family doctor knows the patient, his or her family and community well, is accessible within 24-48 hours and has sufficient diagnostic resources and support units for physiotherapy, mental health and others.
2. Hospital systems that provide diagnostic tests, treatment and counselling within a reasonable period of time.
3. Emergency systems that deal with serious issues on the spot.
4. Information systems that unify health data and allow its shared use by the different professionals attending the patient, as well as enabling communication between professionals.

It is essential to use mathematics for the benefit of the patient. Having a health problem is a probabilistic question, the episode can be banal or serious. Bayes' theorem tells us about conditional probability. The family doctor will work with an enormous margin of uncertainty and with low frequencies of serious illnesses. The hospital doctor will work with less uncertainty and a higher frequency of severe illness. Both will work with different conditional probabilities and will improve their performance if they are able to coordinate properly. In this way, the good work of the former will favour the good work of the latter, save costs, avoid problems for the patient and improve patient safety.

In this way, the family doctor who knows the patient is responsible for assessing whether the process may be minor or whether there is a possibility of it being serious. On that decision rests the entire weight of today's huge and complex healthcare system. The problem is that we still do not understand that this is the basis of the whole health system and it is essential that professionals, citizens and managers are clear about this in order to achieve the best possible primary care so that the best possible hospital care can function.

Anything that helps and facilitates this decision will reduce medical errors, make the healthcare system sustainable and allow for high-quality technical and human care. Anything that hinders it will increase errors. For example:

• Making it difficult and discouraging a family doctor from staying too long in the same position with the same patients.
• Increasing their workload to more than 40 patients per day or less than 10 minutes per visit.
• Having poorly calculated workforces that force doctors who are absent many days a year to take on the burden of care and have to be seen by another doctor with a full schedule.
• Having a deficient electronic medical record model or information systems.
• Not being well coordinated with other colleagues in primary care, in the reference hospital or in the field of management.
• Not having managers committed to the proper functioning of the system.

A health centre where the professionals have to take on the burden of the time and effort required to manage the system.

A health centre where professionals have to take on the burden of the schedules of doctors who are absent many days a year, forcing the number of patients seen per day to exceed what is prudent, will inevitably generate problems of mismanagement of diagnostic tests and treatments (by default or excess), diagnostic delays and patient safety problems. The same will happen with collapsed hospital emergency services or with increased waiting lists for both hospital consultations and surgery. 

With well-trained, motivated and not burnt out healthcare professionals

Having a good medical training system is not easy. In the case of Spain, the MIR system allows the level of excellence achieved to be high, in addition to the high curricular profile required for access to medical schools. 

The same can be said of the rest of the health professions in Spain, which involve a high level of theoretical and practical requirements. 

The characteristics of the bio-health area mean that those who approach it tend to do so with a high degree of motivation, one of the most feared dangers being that of ending up burnt out by the hardness of the work, by the daily contact with pain and human suffering, by the overload of care or by other factors. 

Maintaining a careful human resources policy, where stability is prioritised, fair professional promotion is allowed and the needs of healthcare workers to reconcile family and other needs are taken care of, should be obligatory. Unfortunately this is not the case, and it is universal practice to allow the concatenation of shifts (18 or 24 hour shifts), job instability for decades in the life of the professional or oppressive working conditions.

With a citizenry that knows how to use the health system well

It is essential that citizens know that the health system is a help in times of illness but that it is not innocuous. All healthcare interventions, from the simplest to the most complex, can cause unwanted harm, which is what we call iatrogenic, and the greater the intensity of the healthcare intervention and the greater the frequency of use of these services, the greater the potential for harm. It would be desirable that socially we assume a prudent use of healthcare and use it as little as possible, far from turning it into just another consumer service industry. We cannot lose respect for the potential harm that medicine inevitably inflicts, a percentage of which can be reduced but which cannot be eliminated. 

The accelerated pace of life in our societies means that minor health problems are increasingly less acceptable, and those who suffer from them wish they would disappear as soon as possible to avoid missing work or reducing their productivity. On the other hand, the ageing of the population means that ailments and the frequency and severity of chronic pathologies will inevitably increase, which will mean more contact with the health system. 

What few people realise is that visiting the health system once a year is not the same as visiting three times a year, or that visiting three times a year is not the same as visiting twelve times a year. Too many consultations overloads a system which, as we have seen in the pandemic, is much more vulnerable than we thought. Taking responsibility for its own survival is a vital step for everyone.

Having trusted primary care professionals who can guide and assist in the prudent use of health services will become increasingly important. That is why it is essential to take care of them and to use them only when it is really necessary.

With health managers and politicians looking after the common interest and the viability of the system

Public health care consumes a lot of resources, more and more as technological development advances. That is why it is vital for politicians to ensure that the system does not collapse. It is essential to prioritise actions and spending and try to avoid being guided only by actions that are politically profitable, such as the construction of hospitals or investments in bricks and mortar, cutting-edge technology or new and costly treatments that have not been shown to be sufficiently useful. 

Spending on pharmaceuticals continues to rise as new treatments become more and more expensive while investment in personnel stagnates or decreases, placing an increasing burden on professionals. 

Without the necessary transparency and the ensuing debate, it is impossible to prioritise certain areas of the system that have been pampered (transplants, complex surgeries, interventional diagnostic processes, advanced diagnostic tests or highly complex units) and others that have been defined or forgotten (primary care, rural health, mental health, public health, etc.).

Health managers have the power to work as mere transmission belts for the directives of the Health Councillor on duty or to act as guarantors and protectors of the health care system.

Health managers have the power to work as mere transmission belts for the directives of the Health Councillor on duty or to act as guarantors and protectors of the citizen and the professional. In our environment, there is a broad horizon for improvement and involvement. Favouring coordination, listening and dialogue is still a pending issue. 

With evaluation, quality and safety systems

Articulating systems of evaluation, quality and patient safety is essential for detecting errors, correcting them and proposing adjustments. Fostering a culture of continuous improvement must include accepting the inevitability of error and the importance of articulating actions to avoid or minimise it. This heading is well accepted in theory by both professionals and managers, but it is still very difficult to implement because of the difficulty in our culture of accepting one's own mistakes and the ease with which it is easy to throw the baby out with the bathwater and point the finger at other agents or the system itself as being responsible.

As can be seen, it is not easy to articulate a response to medical error. Talking about it is a first step, as it is essential to ensure that it is not a taboo in order to get closer to reducing it. Building on continuous improvement and not on judgement and condemnation is therefore basic, as experts and common sense tell us. To this end, it seems essential to promote transparency and trust between society, professionals and managers. And above all, to try to play fair, seeking the common good. 

@doctorCasado
Link to blog "La consulta del Doctor Casado"

Suggestions for further reading on the subject:

- Blog Advances in Clinical Management "The diagnostic process and medical errors"

- Uned "Seguridad del paciente y gestión de riesgos"

- Blog Advances in Clinical Management "Saving plans: 5 errors /5 proposals"

- Blog Advances in Clinical Management  "The slow progress of clinical safety, a problem of many hands"

- The Oncologist "Medical mistakes: A workshop on personal perspectives"

- Jossey-Bass "Error reduction in a Health Care"