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Figure: emergency medicine, medical malpractice, physicians, system error
FigureSystem designers must reduce the mistakes they cause or be held medically and legally liable
Errors in the emergency department are a harsh reality for emergency physicians. Our jobs require us to see any condition in patients of all ages and backgrounds with myriad concurrent complicating external factors, such as ED violence and crowding. Such complex and error-prone systems create the potential for disaster given the consequential nature of our decisions.
Progress on ED errors is consistently hampered by attribution bias—the fallacy that an error must be attributed to an individual. So much of the context of our decision-making is out of our control, and we should focus on medical errors as rare but probabilistic occurrences whose frequency is dictated by the systems in which we practice.
Weaknesses in the Systems
Tommy Hastings, an attorney and the founder of Hastings Law Firm, which specializes in medical malpractice in Texas, said physicians don't feel as much ownership of patient care when they are turned into assembly-line workers. “Do corporate profits become a part of the decision-making?” he asked. “Things that have been handed down from several states away, policies that may or may not apply to their community? I think privatization of medicine is a bad, bad trend.”
Malpractice attorneys are often vilified by physicians, but Mr. Hastings said an attorney's role is to force the system to improve. “First and foremost, my profession has to do a better job of identifying systemic issues,” he said. “Sometimes it's easy to just see somebody that made a bad call and pick the low-hanging fruit, and that's the end of the case. But jurors tend to award more money on systemic issues because they expect more from corporations. Where are the weaknesses in our systems? Where have they been pointed out and ignored?”
Unfortunately, systems may not always prioritize effective error reduction. Arthur Diskin, MD, an emergency physician and the vice president of EMPAC RRG, a risk reduction group in Florida, said the system may not have the funding to react on every one-off medical error or malpractice case to reduce its incidence. “What you're looking at is return on investment,” he said. “If you've had one malpractice suit for a missed drug dose due to renal failure, you're going to have a very different reaction than if you've had 10 similar cases.”
Dr. Diskin said the patient sustains an adverse outcome, and the doctor experiences a negative impact on his career. “So, the doctor is clearly also a victim,” he said. “And in some of these cases, the public is a victim. If a hospital has to pay a $20 million settlement, that $20 million has to come from somewhere. That means there's less money available to provide health care to the remaining population.”
The problem may seem insurmountable, but Mr. Hastings suggested that lawyers and doctors work together to fix the systems that cause the problems. “If one life is saved, it's worth it,” he said.
Physicians Feel Blamed
I surveyed EPs to understand better how system factors affect the propensity for error. I used a procedurally-generated case questionnaire where factors about individual cases were randomly manipulated, increasing or decreasing the perceived contribution of system error. I also asked physicians how system factors affected their experiences with error. Ninety-nine physicians completed the survey.
Physicians felt system factors contributed overwhelmingly to their most recent adverse outcome, and they were pessimistic when asked how much others would say system factors contributed.
Their pessimism is warranted. I used multiple ordinal logistic regression to determine which factors about the cases they felt contributed to system error. Physicians were randomized to receive the procedurally-generated cases before or after being asked about their experiences.
Physicians who were asked about their experiences with system factors before encountering the cases were 1.7 times more likely (95% CI 1.1-2.7, p=0.02) to attribute the adverse outcomes in the cases to system factors. Put another way, a physician not reminded of his own vulnerability was half as likely to attribute adverse outcomes to system error. Other significant contributing factors were if a patient was first seen by a nurse practitioner, if a patient was seen in the waiting room, or if the shift was busy.
Legally Liable
We must get out of our own way and scrutinize the system in which we operate rather than scrutinizing each other.
Error is unavoidable, and success is probability reduction rather than avoidance. The most important determinants of error can be found long before an error occurs because propensity for error matters far more than the event itself.
The greatest responsibility for many adverse outcomes lies with the designers of these systems. Doctors can identify factors that increase their chances of making mistakes, so why is the null hypothesis that systems can ignore these factors? We must demand that these systems be held responsible for reducing the probability of error. They should be held medically and legally liable if they don't.
DR. BELANGER is the chief data officer of TotalCare (totalcare.us), the chair-elect of the American College of Emergency Physicians Workforce Section, and an emergency physician in McKinney, TX.
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