Hospital Error

HOSPITAL ERROR....Two large studies, published today in the Journal of the American Medical Association, found that cutting the grueling work hours of doctors-in-training had little effect on reducing hospital errors and patient deaths. Surprised? So were the researchers who did the studies.

There are three possible explanations. One, most errors aren't caused by groggy, sleep-deprived, over-worked residents, so giving them more time off won't make any difference in the error rate. Two, the new regulations, which cut residents' typical workweek from 100 hours to 80, didn't reduce their hours enough to make a difference. I mean c'mon, 80 hours a week still doesn't leave much time for eating and sleeping and all those romantic couplings we see on television shows like "ER" and "Gray's Anatomy." Or, three, the number of mistakes made in hospitals is so large, any drop in the errors committed by residents was too small to be measured.

My vote goes to . . . well, let me just offer a couple of statistics. In its seminal 1999 report on the subject, To Err is Human, the Institute of Medicine estimated that as many as 98,000 American patients are killed each year by medical error. Hospitals are such complicated places, the ways that care givers can screw up are almost too numerous to count. A doctor can accidentally perforate a patient's colon during a colonoscopy, leading to infection. Surgeons leave devices or sponges inside wounds and stitch patients up. One intensive care unit that tracked near misses reported 1.7 errors per day per patient, about 30 percent of which could have been serious or fatal.

I know a doctor who was asked by another physician in the ER to check the blood pressure on both arms of a patient wracked with chest pains. When he couldn't get a proper reading from one arm, because the man was writhing in pain, the other doctor assumed the patient's blood pressure was the same in both arms. That meant the patient might be in the throes of a heart attack. In fact, he was suffering from a dissecting aortic aneurysm -- a rupturing abdominal blood vessel -- not a heart attack. He bled to death internally before anybody figured it out.

Maybe letting residents get some rest will eventually bring down the error rate, but I doubt it. Here's why. Rested residents aren't nearly as important to reducing errors as coordinating the care that everybody in a hospital delivers.

The two studies published today suggest why that might be the case. The studies included 318,000 veterans who were cared for at Veterans Administration Hospitals and another 8.5 million Medicare recipients. It turns out, error rates did go down at VA hospitals, but not at the other hospitals in the study.

When it comes to reducing medical error, the VA health system has three things going for it that most other hospitals don't have. Numero uno, every VA hospital has a fully-functioning electronic medical records system.

This system not only helps physicians and nurses avoid many kinds of errors, like giving a patient the wrong drug, it also allows each hospital to track the treatment of every patient. Hospital safety officers can easily give physicians and nurses feedback on how they're doing when they implement any sort of error-reduction program. Other hospitals are left flailing along, hoping that they are making a dent when they initiate some new plan. VA doctors know -- and in real time.

And finally, VA hospitals do a better job of coordinating all the different people who have a hand in a patient's care. Veterans don't tend to fall through the cracks during hand-offs between one shift and the next, for instance. That's why my colleague Phil Longman's book about the Veterans Health Administration is titled Best Care Anywhere. It's also why a Democratic presidential candidate will probably be pointing to the VA in a speech later this month as oe model for improving American health care.

NOTE: Longman's book is based on an article he originally wrote for the Monthly back in 2005. You can read it here.