Another installment of the #PWChat series took place on Wednesday, August 15. It was co-hosted by Matthew Loxton, MKM, CKM, and the discussion focused on medical errors and was largely influenced by his blog post on this subject.

Topics included: what makes the declaration of medical errors as the third leading cause of death in the US a controversial statement to make, the wide-ranging estimates in mortality due to medical errors found in several studies, why medical errors will never be 100% eliminated, and much more!

Below are the highlights from the chat. You can read the full transcript here, by scrolling down to the corresponding responses.

Click here for a look at our #PWChat schedule and recaps.

 

 

 

Question 1

Q1: What makes the declaration of #MedicalErrors as the third leading cause of death in the US a controversial statement to make?#PWChat

— Physician’s Weekly (@physicianswkly) August 15, 2018

T1 Three big things. Firstly, we are not collecting the cause of death data in a comprehensive, standardized, or consistent way.

So everything is always a guess. The CDC WONDER data (count) is orders of magnitude lower than the BMJ and other estimates
/2#PWChat https://t.co/AttBxYgB6C

— Matthew Loxton (@mloxton) August 15, 2018

/ T2
Secondly, it was immediately leapt on by the press (and politicians) and they lambasted physicians in a very unproductive and unhelpful way,

That just led to exaggeration, defensiveness, and confusion.

It made real progress that much harder#PWChat

— Matthew Loxton (@mloxton) August 15, 2018

Thirdly – psychologically, it is really hard to accept that the therapeutic environment is so deadly!

To be up there as the third leading cause of death, is just cognitive dissonance in spades!

Clinicians are burning out , now they are also a cause? Hard to digest.#PWChat

— Matthew Loxton (@mloxton) August 15, 2018

A1: It signifies we have ample room for improvement in healthcare which makea us uncomfortable because we do our best to do no harm. #PWChat

— Mamata Majmundar (@MajmundarMD) August 15, 2018

 

 

Question 2

Q2: Studies estimating mortality due to #MedicalErrors have resulted in wide-ranging estimates (https://t.co/xP6mmmxheN, https://t.co/SyixIaC8S9, https://t.co/m3i0uFGjVM). Why is it important to not denounce these numbers as wild guesses or underhanded attack on MDs?#PWChat

— Physician’s Weekly (@physicianswkly) August 15, 2018

I think it’s important TO denounce them as they breed an unnecessary fear of the medical profession and they encourage quacks to trumpet the numbers. #PWChat

— Skeptical Scalpel (@Skepticscalpel) August 15, 2018

Q2 Data collection on medical error is a broad topic – what/who defines it, measures it, responds to it for whom at what age, health status, support systems. Ex: Is a patient’s lack of eye sight an error bc there is no HC provider near by? #PWChat

— ElizabethKelly, Ph.D (@Elizabe85727641) August 15, 2018

Question 3

Q3: Why do you say in your blog post at https://t.co/mPwSdJqOYR that—although both estimates and counts of deaths from #MedicalErrors are not trustworthy—the numbers aren’t as relevant as the fact that people are dying of medical error & we have the tools to reduce it?#PWChat

— Physician’s Weekly (@physicianswkly) August 15, 2018

Q3
The simple fact is that we KNOW that people are being injured or killed by medical mistakes.

We KNOW it is much higher than it could be.

That’s what the focus should be on, rather than quibbling about the number#PWChat https://t.co/LnPc6cWev0

— Matthew Loxton (@mloxton) August 15, 2018

Q3 It is easier to deal with numbers than the people represented by the numbers. Since HC has taken on a bottom line approach, with measurement as the impt tool, what brought us to this point (the process) is ignored. Also lost are ethics. #PWChat

— ElizabethKelly, Ph.D (@Elizabe85727641) August 15, 2018

Question 4

Q4: Why do you think it is that PW blogger @Skepticscalpel–who is actually here for today’s chat!–says, in his blog post at https://t.co/Nd61WFbXHf that medical errors will never be 100% eliminated? #PWChat

— Physician’s Weekly (@physicianswkly) August 15, 2018

Hospitals need to be prepared to take all the right steps when a serious adverse medical mistake occurs to mitigate harm and avoid future errors. Check out @LeapfrogGroup’s fact sheet on #neverevents: https://t.co/4rlAXVKv8n #PWChat

— HospitalSafetyGrade (@HospSafetyGrade) August 15, 2018

A3: Another thing to keep in mind is that all humans make mistakes. We can’t place blame on individuals when medical errors occur. Instead, health care teams need to put new systems in place to ensure the same error is not repeated. #PWChat

— The Leapfrog Group (@LeapfrogGroup) August 15, 2018

Question 5

Q5: What factors are known to cause #MedicalErrors resulting in morbidity or mortality?#PWChat

— Physician’s Weekly (@physicianswkly) August 15, 2018

Many causes, and a large number that just keep showing up, such as:

• Poor workflow
• Interruptions
• Badly labeled medications
• Distracted clinicians
• Bad engineering in devices
• Profit motive
• No “stop the press” button to halt a bad flow
• Blame!#Pwchat https://t.co/HXl39nO69m

— Matthew Loxton (@mloxton) August 15, 2018

Question 6

Q6: How can quality-improvement tools such as the “five why’s” and the Ishikawa “fishbone” diagram, help find the root causes of #MedicalErrors leading to fatalities?#PWChat

— Physician’s Weekly (@physicianswkly) August 15, 2018

Q6

So first a caution – these are just tools, we should never view them as a gospel or an objective. Don’t fall into analysis paralysis or tool-worship.

The tools do focus the mind, and shape the approach, and this is helpful. /2#PWChat https://t.co/Xfh6n9sQSL

— Matthew Loxton (@mloxton) August 15, 2018

/2
Root cause analysis uses the fishbone diagram to prompt thinking, and this is useful

Yes the nurse admd the wrong medication, but why?

What policies were involved
What equipment factors,
How did the environment contribute to the error. Etc.

Moves away from blame#pwchat

— Matthew Loxton (@mloxton) August 15, 2018

Q6 Reward suggestions for improvement, finding errors, encourage staff to share interesting case studies that can examplify areas of needed change & who should be involved. This is a community effort bc HC is a community. #PWChat

— ElizabethKelly, Ph.D (@Elizabe85727641) August 15, 2018

Question 7

Q7: Why is it practical and effective to focus on near misses in finding causes of #MedicalErrors, asses how error is reported, and how medical errors are captured as contributory causes of death?#PWChat

— Physician’s Weekly (@physicianswkly) August 15, 2018

Q7
One of the problems with error analysis is that they deadly errors are actually infrequent compared to opportunities.

The death is also too late to change.

/2#PWChat https://t.co/CqVWt6znCH

— Matthew Loxton (@mloxton) August 15, 2018

Q7
/2
What we need is a good predictive indicator that happens in large enough numbers to be statistically and analytically useful, and which reduces the odds of death

Near misses are both far more frequent, and are an unbiased leading indicator#PWChat

— Matthew Loxton (@mloxton) August 15, 2018

Question 8

Q8: What other approaches to minimizing #MedicalErrors seem valid and likely effective?#PWChat

— Physician’s Weekly (@physicianswkly) August 15, 2018

Q8
The biggest is also the easiest.

Ask patients
Ask frontline staff

Recruit them to spot quality and safety risks, issues, and missed opportunities.
Empower them to come up with solutions (not workarounds)#PWChat https://t.co/04g0w3WTlk

— Matthew Loxton (@mloxton) August 15, 2018