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Patient Safety Being Left Behind

Oct 11, 2000

An overworked nurse infuses the wrong type of blood into a patient. An experienced pharmacist puts the wrong drug in a child's medicine bottle. A less-experienced surgeon blows a heart procedure that is performed more frequently and flawlessly down the street.

All the patients die, victims of medical errors. Up to 98,000 such deaths a year, perhaps the nation's most disturbing health care statistic have health officials scrambling to find fixes. They are spurred by an Institute of Medicine report last November that named errors made by doctors, nurses and hospital workers the USA's eighth leading killer.

Problems Well Documented

What they've discovered are glaring problems in the health care system, many of which are expected to be at the heart of a new institute report in the next few months. Among them:

Too many modern drugs and treatments for doctors to keep in mind as they rush from patient to patient.

Nurses taking on more work as pharmacies and other hospital departments close early or reduce staff to save money.

A shift toward performing more surgeries in less-regulated facilities outside hospitals, such as doctors' offices and clinics, putting patients at greater risk.

And, in perhaps the most worrisome development, a slowness by the medical community to embrace technology that could help doctors avoid errors. Not only does the situation create more risk for patients, it has slowed progress. The federal government has declined to approve some drugs, for example, because it can't trust doctors to remember their complexities.

"Medicine, the way it's practiced in the United States today, can be pretty unsafe," says Andrew Wiesenthal, a Permanente Federation doctor who is overseeing the development of a computer system to help Kaiser Permanente practice safer medicine.

Improvements must be made, he says. "There is a moral imperative about it."

He and others are following the technological success of the Veterans Affairs hospital in Washington, D.C., where physicians use a $365,000 computer system that scans bar codes on patient bracelets and medicines. If a doctor is about to make a mistake, such as giving a potentially fatal dose of medication, the system recognizes the conflict and displays a warning.

"The VA is the leader in patient safety," says Lucian Leape, a Harvard researcher in medical safety and quality. "Every hospital should have that. The VA is showing that this can be done. They're doing it."

But health care largely has failed to keep up with the technological advances that have improved customer satisfaction in other services.

"It's a sad fact that health care could benefit greatly from information technology, and it just hasn't been pursued with enough aggressiveness," says Ken Kleinberg, an analyst at Gartner Group, a technology advisory firm that works with health care systems.

For Many, Too Late

In Boise, Sue and Pat Sheridan wish the hospital that delivered their son had used a computerized safety net that might have prompted doctors to test their infant for a common and easily treated problem. After his birth in 1995 at St. Luke's Regional Medical Center, their son, Cal, developed jaundice. In a lawsuit against the pediatrician and hospital, the couple argued that Cal wasn't given a blood test that could have detected dangerously high levels of bilirubin. Now 5, Cal has brain damage.

Lawyers for the hospital argued that proper procedures were followed, that not every child who has jaundice requires a bilirubin test, and that Cal's condition may have had another cause.

After a trial, a jury voted against the Sheridans. But the judge ordered a new trial, saying he believed the evidence showed there was a mistake. The Idaho Supreme Court is to decide early next year whether to grant a new trial.

"The system has to change," Sue Sheridan says. "We are a wealthy country, and we can figure out all of these high-tech things, but we are missing some of the most basic steps in medicine when it comes to communication."

She says patients deserve automated safety nets.

"When it comes to something like sending a report to the doctor or my son getting a simple test, my gosh, what has happened?" she asks. "It's been a really disturbing insight to the medical system."

Beyond Human Capacity

The closer she and others look at the medical system, the more complex and mind-boggling it appears. Each drug approved for use in this country, for example, comes with detailed instructions. The Physician's Desk Reference, which contains all of the drug information today's doctor needs, is about 3,000 pages of fine print. Doctors also must track dietary supplements, new high-tech devices and expanding treatment options.

Part of the fallout: Some doctors are not able to keep up with key details, and medical advances don't reach all patients.

"It's impossible for everyone to know all they need to know," says Michael Cohen, president of the Institute for Safe Medication Practices.

One deadly example of doctors' struggles to keep up is the drug Seldane. In 1997, the allergy drug was removed from the market after hundreds of users died.

The antihistamine had been the first prescription drug to relieve allergy symptoms without causing drowsiness. It became wildly popular, and doctors wrote 6.5 million prescriptions for it in 1996. But when taken with the antibiotic erythromycin and other drugs, Seldane was known to lead to fatal heart problems.

When the FDA investigated, it found that the deaths were to be expected because doctors had not followed the criteria within the fine print of the drug's label. Most of those doctors had prescribed Seldane when their patients were taking other drugs known to pose a deadly risk.

The FDA issued a letter to all doctors urging them to be more careful, but the deaths continued, and the agency decided to remove the drug from the market when a safer alternative, Allegra, was ready for the market.

"Seldane was a huge drug, and it was a fine drug if used appropriately. But the system proved incapable of preventing the drug interactions," says Peter Honig, director of the FDA's office of post-marketing drug risk assessment.

Worse, like a parent that can't trust a child, the agency has refused to approve some drugs because it has deemed the system incapable of such precision.

"We've learned our lesson," Honig says. "The medical care system is not able to manage the risks."

VA System Redices Human Errors

But technology is available to cut through all the complexity. At the VA, its widely praised computer system in use for the past year reduces errors, monitors treatments to see what works best, and tracks patient improvement. Before a patient is given any drug in a VA hospital, nurses and doctors use a laser scanner - like those wielded by package couriers - to seek an instant consult.

The safety check is quick and easy. First, the nurse or doctor scans the identification bracelet on the patient's wrist, causing that patient's medical record (with pictures) to appear on the computer screen. Then the bar code on the drug is scanned. If all is fine - the drug has been ordered by the patient's doctor to be given roughly at that time - the computer gives a green light and instantly changes the medical record to show that the treatment was given.

. It's fast and helpful, staffers say, unless the patient is about to suffer a medical error. "Then," says Lee Ferguson, one of the Washington VA's 117 physicians, "it gets in my face. It says, 'Are you sure you want to do this?'"

The result is that medical errors from bad handwriting, rare drug interactions and human flubs have been largely eliminated.

"There has been a striking reduction of errors that has occurred in this hospital," says Fletcher, chief of staff at the VA center.

He declines to give numbers.

"Their kind of integrated system is clearly the way all health care has to go," says Jed Weissberg, a Permanente Federation doctor who has helped to launch a similar, but more limited, $1 billion system within that private health care system. "We are in the painful process of developing ours as an integrated system. It's easier when the head of the VA or Department of Defense can just give an order and have things happen and people obey. We are learning from the VA."

Kaiser Permanente is considered a leader in applying the technology to the HMO industry. But Kaiser's difficulties launching its own system are just a symptom of the health care system's failure to apply basic computer technology that other businesses have used to improve quality and customer service.

"There is a great deal of cultural inertia behind that," Weissberg says.

Because health care is often viewed as an art as much as a science - and because doctors resist being told how to practice medicine - the computers that recommend the best treatment options and warn of possible drug dangers have been slow to catch on outside of the billing office. Now health care finds itself ill prepared to apply the new technology to the patient.

Among the hurdles: Medical records are handled inconsistently. One computer may code a man's gender as a "1," while another uses an "m" and another "male." When medical computers try to talk to each other, the clash of symbols can cause cyber-gibberish.

"The systems that people are using to manage pharmacies or laboratories don't produce uniformly codified data that talks the same language," Wiesenthal says.

Because Kaiser has its own labs and pharmacies, it is expanding a system Wiesenthal helped develop in Colorado to the rest of the Kaiser system across the nation. The system is expected to be in every Kaiser clinic by 2002.

But the rest of the medical world is not so simple.

Even if doctors outside of the Kaiser system could get their computer to talk with the pharmacy across the street, how would they hook up? "The glib answer is the Internet," Wiesenthal says.

But the amount of information contained in patient records makes today's Web tools still too slow to keep up with the fast-paced doctor making rounds. A patient record, with X-rays and EKG tracings at the doctor's fingertips, can be too huge a data file to download. And security is not yet good enough to protect patient records on the Web. Payoff In Patient Care

Still, indications are that, when done well, such systems increase quality. The VA's computer system goes beyond error prevention, for instance, and reminds doctors of the latest care criteria for disease like diabetes and high blood pressure. A recent study found that these computerized reminders - from recommending a blood test to counseling a patient about diet or smoking - are improving VA patients' care. More study is needed to determine why the benefits began to decline over time. "Diabetes care used to be simple," Ferguson says. "Now it's much more complex." But by following computer prompts to examine diabetics' feet and analyze their blood, he and other VA doctors believe they can reduce the number of amputations and heart attacks their patients suffer.

The concept is based on findings from studies in the medical literature. But unless they are involved in the groundbreaking research, doctors are historically slow to implement new treatments that are detailed in printed guidelines.

"You can pass those out on paper, or you can put them in automated reminders in the computer system," Fletcher says. "Computer reminders go in very quickly and create a more uniform type of care." And Fletcher can use the database to watch doctors and see what kind of care is being given.

This kind of oversight would take researchers poring through paper charts to determine what tests were run, what the results were, and what the outcome was. All of those questions were hard to answer without being in the exam room with the doctor and the patient. Now, answers come in a flash.

Meanwhile, privacy advocates are watching the VA system closely for breeches. Ferguson says doctors at first feared the system would be used as a report card, and many didn't like being watched. But now the teams of doctors compete for good results. "We can (see) a report every week," he says. "If we're trying to reach a goal, we can see what that involves over time."

Now other hospital systems are talking with the VA about buying the software. Because the software was developed using tax dollars, VA charges only $25 for the program that will run an entire medical network. The VA spent about $365,000 on the laptops, handheld laser scanners, wireless network gear and other hardware. An amount, staffers like to joke, that is less than the average medical errors lawsuit settlement.

"Doctors are very good and very sophisticated, but there are so many little items that need to be followed up on for good patient care," Fletcher says. He says that if medicine plans to improve quality it will have to turn to computers: "It is the way."


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