Don't Hurt Me, Don't Kill Me and Don't Make Me Suffer Needlessly

I have had a number of occasions to quote the gentleman who first wrote these words, but last week I finally met Roger Resar face to face.  Resar, a senior fellow at the Boston-based Institute for Healthcare Improvement and Assistant Professor of Medicine at Mayo, was addressing a room of healthcare leaders from North Shore LIJ Health System on the Global Trigger Tool, an innovative method for detecting, measuring and tracking adverse events, one that he helped develop.  Using it doesn't reduce harm, but it does make it detectable.  And this is a critical first step.

I had believed for a long time that the core issue in patient safety is identifying and preventing medical errors.  That view, I now think, is logical but wrong, or at least seriously incomplete, and this was Resar's message.  Patient safety is not principally about errors, he suggested, but about harm.   There are several reasons to defend this position. First, errors are generally hard to define and hard to detect. Additionally, studies confirm that most errors don't lead to harm.  It is simply not efficient to set our sites on the elimination of error from the hypercomplex environment of healthcare.  As a matter of fact, the pursuit of individual errors generally leads to interminable and vigorous debate about the relationship between the alleged error and the outcome.  Reputation and ego are often at stake.  Uncertainly prevails. This is a cul-de-sac and such discussions are mostly obstacles to progress.  Finally, when we focus on errors and away from harm, we tend to overlook many important opportunities to improve.  Today's "expectable" complication is an innovation away from the history books.

But wait, we say.  What about wrong-site surgery?  Or the calculation error leading to massive overdose and death in the ICU? Clearly these front page news events are as real as the connection between the fateful error and the tragic outcome.  We must pay attention.

Indeed we must.  However, these events are anomalous, describing a tiny fraction of all harm that occurs in hospitals today.  More than a decade after the Institute of Medicine opined that 100,000 patients a year die in hospitals due to "preventable adverse events"  we are hardly any closer to winning the war on harm.  The best studies suggest that three of every ten hospital admissions is still associated with an event that causes temporary harm, permanent injury or death.  It is time to change tactics.

Everyday miracles in the ED

Earl is an "environmental service worker" in our Emergency Department.  His formal responsibilities include mopping floors and removing trash.  Wearing his tan, hospital-issued uniform, he is tall and lean with graying hair and would make one think of the actor Morgan Freeman. I have changed his name but the following letter and the events it describes are very real...

Dear Earl,

On the evening of Friday, May 10^th my father-in-law was brought by ambulance to the Emergency Department after a serious fall and spinal injury.  You were on duty that evening. 

I saw many things happen in the ER that night.  Few of my memories, however, are more vivid than those of your kind and very meaningful gestures, your expressions of empathy and words of consolation, not just for our family but for many others as well.  I have the sense that this is something you do every day.  I recall in particular when you went to the bedside and saw an anxious 19 year old girl, our daughter ______, leaning in and holding the hand of an older gentleman on a stretcher.  He was grimacing in pain and she was looking shell shocked, and you said “you must be so worried about your grandpa… It really is going to be OK.” 

Hospital leaders spend a great deal of time trying to promote a culture of caring.  This is true not only because measures of Patient Experience are now publicly reported, but because providing compassionate care is what we are all here for.  Thank you very much for being a true leader by making patients and families feel better, and showing all those around you how it is done.  We would be grateful if you would agree to attend an upcoming Administrative Meeting so that you can share your ideas with the hospital’s senior staff.

Please accept my most sincere thanks for everything you do.

Yours truly,

Michael B Grosso

Diagnosis: why checklists wont do the (whole) job

Perusing the National Patient Safety Foundation website this morning, I noticed a page for patients entitled "Checklist for Getting the Right Diagnosis."  If only it were so simple.

It shouldn't be surprising that a group like NPSF would focus on a "systems" approach to the problem of diagnostic error.  After all, a key learning of the patient safety movement has been that healthcare errors in general can best be understood not as the individual failure of a doctor or nurse, say prescribing or giving a wrong medication, but as malfunctions of our hyper-complex healthcare delivery system susceptible to improvement with more reliable processes, communication protocols and standardization.

So when leaders are confronted with the widespread problem of diagnostic error, it is tempting to fit this issue into the very same framework, and to start thinking about systems-based approaches to a fix.  Hence, the checklist for correct diagnoses.  Therein, patients are advised to be good and accurate historians of their ailment, to keep track of their own test results and, most significantly, to "ask the physician, as a matter of routine, 'could this be anything else?'"  (Presumably this mental jog is intended to influence the physician to think more broadly about the patient's problem, and consider alternate diagnoses.) Here's the problem.

Physicians frequently weigh several diagnoses based on the patient's history and physical examination, narrowing the possibilities as they go on.  This is not a cut-and-dried affair, however.  Common conditions, as a med school aphorism goes, occur commonly.  Uncommon explanations are generally reserved for situations where it is so important not to delay the rarer diagnosis that it is acceptable to consider it seriously until "ruled out" with further investigation.  A common complaint may also point to an uncommon diagnosis when the clues just aren't "adding up" to any of the garden variety explanations - as when the pain is too severe, the duration or tempo of the symptoms is wrong, or a physical finding (like an enlarged lymph node or a peculiar rash) just doesn't make sense in the context of the "usual suspects."

This kind of thinking is dynamic and, one hopes, improves with the experience of the practitioner.  Doctors in training have trouble separating what's relevant from what's not, and so develop long lists of possible diagnoses, even for common complaints, where their supervising physician will quickly hone in on one or two.  As one might imagine, the process is potentially error-prone, which is what makes diagnosis the hardest part of medical practice.

I remember a day some three decades ago in the Pediatric ER at the New York Presbyterian Medical Center.  I was the senior resident, supervising an intern on a chilly January day.  He was presenting a perplexing case - fever, headache, and multiple organ system involvement - coughing, nasal congestion, joint and muscle pain, nausea and lack of appetite.  And yet, the patient's physical examination, beyond a clear nasal discharge, was "within normal limits."  He was clearly baffled. After he reviewed a series of arcane tests and investigations aimed at getting to the bottom of this,  I posed the question..."so why don't you think this is the flu?" 

On the other hand, physicians can go on mental autopilot and fail to recognize when the need exists to think outside the box.  Here's the challenge though - how to be sensitive to the rare bird without taking too many patients on chases of the wild goose, which cause their own problems.  Beyond the matter of cost, the diagnostic Sherlock Holmes will surely cause much unnecessary anxiety and mental anguish, and, from time to time, cause physical harm by aiming a machine gun of tests and treatments at problems when a fly swatter would suffice.

So here's my version of the one-size-fits-all diagnostic checklist.  One: did I remember to listen to the patient?  Two:  have I thought through the problem to the best of my ability?  Three: have I communicated my thoughts clearly to the patient and family?  And finally:  have I checked my hubris at the door?  Because being a good physician means never getting too infatuated with our own ideas and always being open to changing course if doing so is in the best interest of our patient.