Ah ne’er so dire a Thirst of Glory boast,
Nor in the Critick let the Man be lost!
Good-Nature and Good-Sense must ever join;
To err is human, to forgive divine.
–Alexander Pope (1688-1744)
According to the prestigious Institute of Medicine, between 50,000 and 100,000 patient deaths are caused each year in the United States by negligence on the part of doctors, nurses, and other health care providers. Nearly 1,000,000 patient injuries per year are also attributed to human error in the delivery of health care.
The presumptive causes underlying negligence in patient care are multiple and varied, and continue to be the subject of much debate among patient safety experts. However, virtually all such experts agree that largely preventable human errors account for the vast majority of patient injuries and deaths associated with negligent patient care.
In the operating room, where I spend much of my time, as a cancer surgeon, we have adopted patient safety “check lists†inspired by the airline industry, and which are designed to reduce the possibility of errors during surgery. At our institution, the patient’s identity (and the surgical procedure to be performed) is confirmed, twice, by everyone in the operating room before an incision is made. Towards the end of the surgical procedure, an additional “debriefing†is performed, and the surgeon reviews the procedures that he or she has just performed. The operating room nurse also confirms that all sponges, needles, and instruments have been accounted for, in an effort to reduce the possibility that any of these foreign bodies will be left within the patient.
One important aspect of physician error is that of errors in diagnosis. In a newly published clinical study, which appears in the current issue of the journal Pediatrics, 1,362 pediatricians at three major academic medical centers, and 109 affiliated clinics, were invited to anonymously complete an Internet-based survey regarding their self-perceived frequency of diagnostic errors. These doctors included experienced academic pediatricians, experienced community-based pediatricians, and resident doctors who were training to become pediatricians. Altogether, 53 percent of the queried pediatricians agreed to complete the anonymous survey.
More than half (54 percent) of these responding doctors indicated that they made significant diagnostic errors at least one or two times per month. Not surprisingly, the resident doctors in training acknowledged the highest number of diagnostic errors, with 77 percent of these trainees admitting to at least one or two significant diagnostic errors per month.
Based upon their anonymous responses, nearly half (45 percent) of these 726 pediatricians believed that one or more of their diagnostic errors had harmed patients at least once or twice per year.
When asked to analyze the underlying causes for their errors, these doctors cited the following explanations: failure to gather adequate patient history information, inadequate physical examination, inadequate review of the patient’s chart, and inadequate coordination of care and communication among the providers involved (“inadequate teamworkâ€Â).
Specific examples of diagnostic errors cited by these pediatricians included viral illnesses being misdiagnosed as bacterial infections, misdiagnosis of medication side effects, misdiagnosis of psychiatric disorders, and misdiagnosis of appendicitis.
When asked to offer solutions to common diagnostic errors, these pediatricians most commonly recommended the implementation of electronic health records, as well as closer patient follow-up.
(It is important to note that, in view of the human tendency to “under-report†personal failures, it is very likely that the true incidence of significant diagnostic errors is actually considerably higher than what these pediatricians have self-reported in this study.)
In a perfect world, we physicians would never make the wrong diagnosis, or miss a diagnosis altogether, or miss an adverse reaction to medications or other treatments. We would never prescribe the wrong medication or perform the wrong operation; and we would never, through acts of either commission or omission, perform anything less than a perfect surgical operation. Unfortunately, the practice of Medicine, as with all human endeavors, will never become a “zero error†profession. However, all of us, both patients and physicians (and physicians are patients, as well), certainly would agree that every effort must be made to drive preventable patient care errors down as close to “zero†as is humanly possible.
While it is unlikely that human error can ever be completely eliminated, in Medicine or in any other profession, the findings of this important study are significant, and point to areas where substantial improvements in the delivery of health care can be achieved by physicians and other health care providers (and, I might add, by patients as well).
Look for the imminent publication of my new landmark evidence-based book, “A Cancer Prevention Guide for the Human Race,†in August of this year.
