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The Personal Becomes Political: How One Death Led to the IOM Report on Preventing Errors

Scheck, Anne

Special Report

This is the story of a medical error in emergency medicine, as only a sister can tell it following a sad encounter between parents and doctors. “My mom knew as she looked into their eyes, and turned to Dad and said, ‘He is dead, Ray!’ Screaming, she ran down the hall to Mike's room. In the doorway, she saw Mike lying there, his arm hanging over the side of the bed, with the IV still in it.”

A “gut ache” had prompted her brother to seek treatment, recounted Roxanne Goeltz in an essay she wrote for the National Patient Safety Foundation. After being given an infusion of morphine for the pain, her brother died, allegedly losing complete consciousness when he was left alone and unchecked. A “sac” around the heart was blamed. “My parents asked them how it got there. No answer, then excuses; there was another emergency.”

Only a few years ago, the poignant details of this case might not have made it onto the pages of a medical newsletter. But this is just where Ms. Goeltz's recollection appeared — right on the heels of the headline-grabbing Institute of Medicine (IOM) Report, “To Err is Human: Building a Safer Health System” (Focus on Patient Safety 2000;3(4):6).

At Emory, anyone — right down to the person who empties the trash — can raise a concern about medical care

The IOM report not only drew a public outcry, including the story of Mike's death, it ignited the kind of federal attention that put medical administrators everywhere on notice. The U.S. Senate held hearings — one of them devoted exclusively to the IOM's recommendations. Another focused on adverse drug events and medication errors, among the most common medical mistakes.

Some saw the IOM report as a condemnation. But in Atlanta and other cities, certain emergency physicians held a different view. They felt it meant that a matter they'd been trying to push forward now had a welcome mat. At Emory University, Doug Lowery, MD, a former Air Force flight surgeon, noted that some members of the national medical community seemed to want to shoot the report down after it launched the troubling data. He wasn't one of them, he said. “I know to many that report is very controversial,” he said. “But we know mistakes do happen.”



Dr. Lowery, the medical director of emergency medicine at Emory, landed in Atlanta more than five years ago with strong feelings that some of the tactics he learned in the military could work in a medical setting. Throughout his medical training, he kept hearing how an error was someone's “fault.”

But in the Air Force, adverse incidents often were seen as the culmination of events, of many failures along a chain in the system, not just a single chink. In hospitals, the same can be said to be true, at least some of the time, he asserted.

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Questions and Concerns

One example is a typical medication error. No pharmacist, he explained, ever grabs the wrong medication without committing an error, but couldn't the way drugs are dispensed be part of the problem? In standard alphabetical order, drugs and medications with similar names are cheek by jowl. Add haste and tension to this situation, and accidents — even lethal ones — are more likely to occur, he said.

Dr. Lowery helped support changes that have made drug-dispensing at Emory's emergency system a program of checks and balances. Not only was there a de-alphabetizing of the pharmacy, but those impossible-to-decipher hand-written prescriptions were done away with, too. In the emergency department, physicians prescribe drugs by typing in the designation at a keyboard, then signing the print-out. He said he hopes an electronic patient history will be included eventually, which can warn a prescribing physician if a potentially harmful drug interaction is likely to happen, he said.

As a result of all these steps, the culture of the emergency department has changed, too, observed Dr. Lowery.

Physicians, from medical directors to residents, are advised to listen to anyone who raises a question or concern about medical care, right down to the person who empties the trash. At Emory, the housekeeping staff can cite a patient complaint, report it, and be assured that there will be no repercussions other than the information will be acted upon in the patient's best interests. “Every observation is important,” Dr. Lowery said. Safety issues are now part of the medical curriculum, he stressed.

It may sound like Emory is the standard-bearer for malpractice prevention. However, this kind of accident-thwarting activity is going on in emergency departments across the country, according to the medical literature.

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A Global View

Around the time of the IOM report, research efforts began to intensify. They focused primarily on error reduction in narrow categories such as radiographic interpretation by emergency physicians (BMJ 2000;320:737) and case analyses that demonstrated how a particular mistake occurred.

These efforts were followed by a flurry of studies that took a more global view, particularly in emergency medicine. Methods to assess the needs of emergency medicine were published (J Emerg Med 2001;20(2):197). In addition, theoretical solutions, such as more standardized forms for avoiding medication errors (Ann Pharmacother 2001;35:953) and improved awareness and adherence to guidelines were proposed (Ped Emerg Care 2001;17(2):83).

At Albany Medical College, Clifford Erickson, MD, the chief resident in emergency medicine, has been documenting what he and his more senior colleagues term “mal-occurrences.” Over the course of a recent study, he and his co-investigators looked into 65 such mal-occurrences, and found they were associated with higher daily census counts.

What were these mal-occurrences? Everything from medication errors to mislabeled lab work. How did they propose to help mistake-proof their department in the wake of the findings? “It's a money issue, and a nursing issue,” Dr. Erickson explained. To lessen the likelihood of mal-occurrences during these peak periods, his institution has been working on ways to ensure higher levels of staffing. Incentives for shifts during times of overcrowding — such as weekends — now include pay differentials and reduced work hours.

For anyone who wonders where such funds will come from in a belt-tightening recession, the U.S. government has announced plans to award research grants and related financial support of up to $50 million in an effort to enhance patient safety and diminish medical errors (

One way in which mistakes can be avoided is to know when and how they occurred in the first place, according to interviews with emergency physicians. But that is easier said than done. When medical errors occur, there is a tendency to cover them up. The very real threat of litigation looms.

“Patients want us to be forthright,” said Cherri Hobgood, MD, an assistant professor of emergency medicine at the University of North Carolina at Chapel Hill. In a study of patients who were queried about how much information they would like to have with regard to a medical error, Dr. Hobgood found that a majority of patients want full disclosure of any medical error and wish to be informed of the error upon its detection.

“I know to many that report is very controversial. But we know mistakes do happen.”

Dr. Doug Lowery

“It's a money issue, and a nursing issue.”

Dr. Clifford Erickson

“Patients want us to be forthright.”

Dr. Cherri Hobgood

“I think that, in general, the more open we are with patients, the better.”

Dr. Andrew Sucov

The results, from a 12-item survey administered to emergency patients and families, also showed that health care consumers believe that medical educators should avoid reprisals for errors during training.

Practical changes can reduce errors, such as de-alphabetizing the pharmacy, standardized forms, and no-fault reporting

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Punitive Actions

Some emergency physicians feel that honesty is the best policy in such situations. “I think that, in general, the more open we are with patients, the better,” said Andrew Sucov, MD, the director of the Davol Emergency Room at Rhode Island Hospital.

Recent reports concur with Dr. Sucov's view. Such studies show that patients want some kind of acknowledgment from their physicians, even for minor errors. Moreover, that acknowledgment may actually reduce the risk of punitive actions, one such investigation has suggested (Arch Intern Med 1996;156:2565).

“Some [patients] will be very upset knowing about errors, but others will rest easier knowing the truth,” Dr. Sucov said.

He speaks from first-hand experience. He and his colleagues in Providence instituted a voluntary and anonymous error-reporting system. Physicians and nurses during a study period were encouraged to report events in which an error occurred or there was a “near miss,” regardless of actual patient harm. A patient safety committee, made up of different specialists, reviewed these incidents, and root cause analyses were performed. Most of the adverse reactions they spotted were from failure to diagnose or lack of appropriate treatment, which constituted about a third of the cases. However, communication errors and system delays were close behind.

Fear of being sued for malpractice is a dark cloud under which many doctors believe they toil; some have called it medicine's growing killjoy because so many consumers have the same expectation of their health care as they do of other goods and services. “The practice of medicine is not the same as the production and sale of widgets. A defective hula hoop is not the same as a fulminant meningitis with resultant long-term disability,” Terence M. Davidson, MD, argued in a journal article that appeared around the time of the IOM report. But he goes on to add: “Many industries are regulated, a classic example being the aviation industry. Physicians have successfully resisted this intrusion, but they seem unable to regulate themselves. Perhaps the time has come for external oversight” (West J Med 2000;172:267).

A movement has been afoot to require reporting any “dangerous reactions” to treatment to the U.S. Department of Health and Human Services. Proponents claim that these types of laws increase individual freedom without increasing consumer risk, but there is counterpoint to that: There already are laws protecting patients from being given medication or devices that have not met federal approval or standards (Consumer Health: A Guide to Intelligent Decisions, 6th ed. Brown & Brown Benchmark Publishers, Madison WI. 1997).

Nonetheless, the IOM report calls for raising the bar by meeting goals such as identifying errors quickly and implementing safety procedures that make them far less likely.

At Emory, one simple measure has been undertaken to prevent the kind of mistake that can occur during the simple act of reading by health professionals, especially among those middle-aged and newly presbyopic. Well-lighted rooms everywhere are now the standard of care, so that aging eyes can see the printing clearly on everything from the patient ID to the markings on a bedside IV.

Dr. Lowery is passionate about such steps because as a chief resident of emergency medicine in southern California years ago he saw cases just like the one described by Ms. Goeltz, whose brother's death caused her to write these embittered words: “There was no compassion for those whom my parents trusted to care for their son. The doors opened, and the whole staff was standing there, whispering. They stopped abruptly, and looked at my parents. … My parents were educated the hard way….”

Dr. Lowery said he is haunted, too, but by another kind of grief. A physician friend made a mortal mistake when both were in training. As chief resident, he tried to console his colleague, but “no matter how supportive I tried to be, it didn't diminish the pain,” Dr. Lowery said. The incident remains fresh and undimmed to Dr. Lowery, even today. He contends that such tragedies leave scars from which there is no recovery, scars that extend not just to bereaved family members, but to the medical staff, as well.

Delivering news of a death affects doctors in a way the public may not understand when they are looking at the somber face of a physician in the hospital corridor. But it is one of the things that prompts him to keep pushing for error prevention, Dr. Lowery said. “This is a situation where everyone is traumatized.”

© 2002 Lippincott Williams & Wilkins, Inc.