'Slips, Lapses, Fumbles': Medical Mistakes Kill, And A Solution Is Seen In Education

Medical negligence kills more than 250,000 people, and harms about 10 times that number, every year. And errors don’t just happen in hospitals: A 2007 study of pediatric malpractice showed that 43 percent of incidents occurred in doctors’ offices.

Pediatric geneticist Aubrey Milunsky, who spent 30 years practicing and teaching at the Boston University School of Medicine, thinks the solution should start with medical education.

Milunsky, currently an adjunct professor of obstetrics at Tufts University School of Medicine, has written 26 books, including, most recently “I Didn’t Know, I Didn’t Know: Avoidable Deaths and Harm Due to Medical Negligence,” which focuses on stories of medical harm, and ways to avoid such tragedies.

Our conversation, lightly edited:

A patient safety movement emerged in 1999 after a famous Institute of Medicine paper identified astronomical rates of death and harm from medical errors. Are you saying that 19 years later, not much has changed?

Nothing has worked in the sense of making a difference to the mortality.

In your book, you mention many different actions you think should be taken to better protect patients. What do you think is the most important?

Every medical student who graduates from medical school [should only be allowed to] do so with a certificate by examination in risk management. Every resident who graduates residency -- usually after three years -- cannot do so and enter practice without a certificate by examination in risk management. Every physician who renews their license -- mostly every four to five years -- needs to do an examination in risk management online.

What would that accomplish?

The effect of the examination is to have people absolutely aware of how mistakes are made. It’s not only a question of how to not make the wrong diagnosis, but the kinds of steps that occur in trying to reach diagnoses, where diagnostic error sits at the top of all the failures -- accounting for 30 percent of the cases.

Can you give some examples of such diagnostic errors?

There are just an endless set of cognitive biases that occur: failure to look at presenting features in the case; looking only for evidence that concerns the first impression; perpetuating a diagnosis that someone else has made; expertise bias -- believing a patient already has undergone extensive evaluation and won’t have anything more to gain from further tests, despite the possibility that the process may not have gone far enough.

So, you’re saying medical personnel aren’t being taught how to identify errors they’re likely to make triggered by the way we all think?

None of this is taught in any significant way and absolutely not by requirement.

Are the problems mainly from a few bad actors?

Most errors are made by good doctors. There are slips, lapses, fumbles, distraction, preoccupation, inattention, laziness, carelessness, thoughtlessness.

But there are a few bad actors, as you note in your description of a Texas neurosurgeon now serving a life sentence for injuring his patients.

He had received letters of reference; chiefs of service had given letters of reference, in order to get rid of him. Never mind the ethics, to me it’s criminal to do that.

We can’t put rules into place to legislate good medical practice, so how do we make a difference?

Errors for the most part occur without intention. It’s hard to avoid or prevent an error from happening if you don’t know it’s going to happen. The point is to understand how errors occur. Teaching from medical students onwards how errors occur will have the chance at least of making a difference for avoidance and prevention.

Now, when a major error occurs at a hospital, a team meets to discuss the error. What do you suggest instead?

Have a conference that sits down to figure out, where are the risks about each thing we do -- to recognize ahead of time where potential risks exist and how they can be avoided, and educate people on that team where they could anticipate a risk and act on it by prevention and avoidance. These are prospective team meetings that are not looking at, "Why the heck did that happen?" But rather, "Wow, can we prevent anything from happening?"

You think this could prevent some errors?

I could harangue you from here to Christmas about the things that go wrong that could easily be avoided. Some are so desperately simple that you’ll be shaking your head and say I can’t believe this could have occurred.

Such as?

Simple errors. A secretary being asked to fax the wrong document; she gets the wrong [fax] number. It’s never received by the physician who’s supposed to get the information -- and a child is born with a genetic disorder.

What can patients do to protect themselves against medical error?

Anybody who goes to a hospital needs to take an advocate with them -- a friend, a relative, somebody else who’s watching what’s going on. Patients who see doctors need to know exactly what they are expecting, what results are supposed to be forthcoming, was the laboratory test result obtained.

It sounds like you’re saying patients should distrust their doctors. But is that really constructive?

People have a need to trust their doctor. When you go and see your physician, you don’t want to walk in [wondering], are you going to kill me? Can I trust you, what are you going to do?

Why do you personally feel so compelled to bring attention to this issue?

This is in fact a national crisis and I don’t notice anybody talking about in that sense. In major medicine, nobody has taken major steps to put a stop to this carnage.