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I made a mistake recently, a fairly serious one.   We don't much like to talk about our mistakes in medicine; when they're not so obvious that the lawyers get involved, or if they aren't so egregious that they get sent to the medical staff quality committee, then they tend to get swept quietly under the rug.  

I don't much like knowing I made a mistake.   I haven't killed anyone so far since I've been doing this job, at least not anybody who wasn't going to die anyway.   I dodged a bullet this time, so to speak; it was a missed .   Fortunately, the outcome was good.   I figure I could privately flagellate myself over this, or publicly flagellate myself on the blog, or I could use it as a springboard to discuss how we deal with errors in medicine.

As one of my hobbies, I am a private pilot.   As a pilot who is committed to not becoming a smoking crater in the ground, I obsessively read the  of aviation incidents.   The NTSB is generally very disciplined about overlooking the single error that was the direct cause of the crash (usually the pilot's failure to maintain control of the aircraft) and dissecting out the chain of errors (there is almost always more than one) and other factors that contributed to the accident.  

Typically, the reports begin with a brief vignette describing the critical facts, and a summary stating the the causes of the accident, and read like this:

The private pilot with 1,500 hours experience took off from Spokane at 9PM local time Feb 18, flying to Seattle, returning home from a fishing trip.  The pilot, a physician, was scheduled to work the 7AM shift in the ER the next day.  No preflight weather briefing was obtained; weather was cold and wet.  No distress calls were recorded.  The wreckage was located in the Cascade Mountains, and analysis showed...(technical details).
Causes of the accident include:

1. The pilot's strong desire to reach the destination in time for his shift.
2. The pilot's decision to take off with inadequate pre-flight preparation.
3. An inadvertent encounter with adverse weather, which led to airframe icing.
4. The pilot's failure to recognize the icing and return to more favorable weather conditions.
5. Continued flight into icing conditions, resulting in increased stall speed and inability to maintain altitude.
6. Loss of visual orientation and subsequent stall/spin.
7. Contributing factors include icing weather, night-time visual conditions, and mountainous terrain.

It analyzes the chain of events, each of which was necessary but not sufficient to cause the accident.  On first blush, many accidents like the above might just be lumped in as "dumb pilot killed himself," which is true enough but not very informative.  In this example, the root cause is what pilots call "get-there-itis," the external pressure to make the trip regardless of conditions.   Other superficially similar accidents might have very different root causes, many of which have been identified and are aggressively marketed to pilots as behaviors to avoid.  

The other side of the equation for aviation is that there is an error reporting mechanism, in which pilots can self-report errors or dangerous situations.   The inducement for pilots to self-report is that they are thereby immunized from any adverse licensure action, absent wanton or deliberate violations.   By developing a culture of safety, where every near-miss is reportable without retribution, where every accident is investigated by neutral parties, it has been possible to make great strides in identifying the most common and preventable factors in accidents. The idea is that we cannot change the environment: bad weather and icing will always occur, but by changing the way pilots interact with their highly complex environment, the rate of adverse outcomes can be controlled.

As a result, the aviation industry has an incredible safety record considering that flying is an activity that can only be done at lethal altitudes and lethal speeds.   But are no similar institutions or procedures in medicine, which is a pity. 

First of all, there is rarely a neutral adjudicating body in medicine.  If there is a corpse to examine, there is probably a plaintiff's attorney there to advocate for the survivors.   The adversarial environment of the courtroom is no place for an objective analysis of fact.  There are two parties advocating their positions, each of whom is interested in the sense that their interests lie in a judgment one way or the other.   The defendants will not voluntarily disclose facts harmful to their case, and the plaintiffs may make .  The ultimate determinations, which tend to favor the physicians, focus on the person -- their competence and the quality of the doctor, and not on the environment and the processes that produced the outcome.   Most cases are settled in private.   Even when a trial's result is public, , the results are difficult to put into a simple "take-home" message, and in some cases, different juries produce contradictory statements.  It's no way to gather data on errors or themes for improving overall quality of care.

Similarly, hospital medical staff quality committees, or the state licensing boards can resemble the malpractice environment, in that they are generally convened due to a suspicion that a doctor has erred or is in some way at fault.  The setting and tone can be decidedly inquisitional.  My personal experience is that the people involved in these procedures have been scrupulous about being fair, but the fact that the physician is afraid for his license and livelihood leads to a defensive and less than open investigation.

The sad truth is that most errors in medicine are simply ignored.  Often nobody is aware of it but the doctor.  If the patient lives, the doc gives a sigh of relief and a prayer of thanks to his deity of choice, and moves on to the next patient.  Maybe he learns from his experience, maybe not, but nobody else does.   If someone else is aware of the error, a colleague or a nurse, the case may be quietly ignored, swept under the rug as an isolated "fuck-up," maybe with an admonition not to let it happen again.    If the patient is aware, or is harmed, some more ethical institutions may have a "disclosure" session or a root cause analysis.  These are rare, and typically involve sentinel events, the "should never occur" errors: wrong-side surgery and the like.   These quasi-tort proceedings often are mostly "damage control" efforts to minimize liability and maybe to a small part motivated by a desire to "do the right thing."  But they are infrequent and tend to consume a lot of attention at the Risk Management/CMO level of administration.  Certainly not a venue for routine cases.

What is needed is a safe method for docs to routinely report the "near misses," like mine, where they can be reviewed and discussed and the contributing factors identified.   Where the verdict won't be "Dr SF is a bad doctor," but "factors X and Y contributed to Dr SF's error which then caused Z."  Where there is protection for health care providers who self-report to encourage the capture of as many cases as possible, to better extract the data and deduce the ultimate causes.

I don't see this happening in my lifetime.  The tort system is too entrenched and consumes too much of the oxygen in the room, and represents a prohibitive barrier to physician disclosures.   Further, the lack of a responsible agency like the NTSB leaves it to individual players to act on their own in error management.   It is too easy for hospitals and doctors to ignore the "sub-clinical errors" and only act when threatened by the tort system or egregious errors.

I know you're all dying to hear about it, so I'll blog my own personal Root Cause Analysis in part two...
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