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MEDICAL WRITINGS Error in Medicine: What Have We Learned? I don't watit to make the wrong mistake. in medicine has become more apparent, people Yogi Berra both inside and outside medicine have begun to examine medicine's systems and processes with this ver the past decade, it has become increasingly kind of "human factors" thinking in mind. Oapparent that error in medicine is neither rare In an early chapter of Human Error in Medicine, nor intractable. Traditionally, medicine has down- Leape reviews the data from the Harvard Medical played error as a negligible factor in complications Practice Study (5). This work was a landmark, in from medieal intervention. But, as data on the mag- large part because it was the methodologically strong- nitude of error aceumulate—-and as the public learns est study of its time to examine the epidemiology of more about them—medical leaders are taking the iatrogenic injury. The study assessed a random sam- issue seriously. In particular, the recent publication ple of patients discharged from New York hospitals of the Institute of Medicine report has resulted in in 1984. Serious iatrogenic injury occurred in 3.7 an enormous increase in attention from the public, percent of hospitalizations (6). On the basis of these the government, and medical leadership (1). results, it was estimated that iatrogenic injury con- tributed to as many as 180 000 deaths annually in the United States (7). This is four times the number Human Error in Medicine of deaths caused by traffic accidents. Other indus- tries have done much better; although airplane Several books have been defining markers in this crashes get headlines, in 1998 no domestic airplane journey and highlight the issues that have emerged. fatalities occurred in the United States. Nonfatal Of particular note is Human Error in Medicine, ed- medical injuries resulting in disability or prolonged ited by Marilyn Sue Bogner (2), pubhshed in 1994 hospital stay occur in another 1.3 million U.S. pa- (unfortunately, currently out of print) and written tients per year (7). Even though medical profession- for those interested in error in medicine. Many of als conscientiously strive to avoid the "wrong mis- the thought leaders in the medical error field con- take," two thirds of medical injuries are estimated tributed chapters, and the contributions regarding to be preventable under the prevailing standard of human factors are especially strong. The book is a care (7). concise and clear introduction to the new paradigm In the human factors section of the book. Cook of systems thinking in medical error. and Woods discuss the difficulties that arise between In the foreword to this book. Reason provides in the "sharp end," practitioners who actually care for condensed form his thoughts about the evolution of patients, and those at the "dull end," persons who theory on the nature of human error and accidents control many of the resources (for example, admin- (3). There has been a transformation in thinking istrators) (8). They argue that although superficial and research about medical error and injury, much analyses are often focused at the sharp end, dull- of which has used information from other indus- end factors are more important than generally ap- tries. Conventionally, the single focus of both the preciated and contribute critically to most accidents. medical profession and the medieolegal system has Later chapters examine how such thinking has been on individual culpability for error. Other in- been applied in anesthesia (9, 10), which has been dustries, however^especially high-risk industries the leading specialty at addressing error systemati- such as aerospace and nuclear power—have pro- cally. Helmreich and Schaefer (9) discuss data on duced enormous improvements by focusing on re- the factors that influence team performance in the designing their systems to minimize human error. operating room and find that interpersonal and Reason, drawing from analysis of such disasters as communications issues play a key role, although the explosion of the space shuttle Challenger and most organizations devote little or no resources to the 1987 Kings Cross underground subway fire in support training in human factors and human inter- London, observes that systems often contain "latent ventions. The authors suggest that more attention to errors"—errors waiting to happen (4). Safeguards, the dull end could provide even better results; how- or "defenses," are often built in but are inadequate, ever, because of a variety of improvements, such as so that a series of failures can easily align to pro- oxygen monitoring, anesthesia has registered the duce disaster. As the extent of the problem of error largest safety gains of any specialty, Gaba—one of © 2000 American College of Physicians-American Society of Internal Medicine 763 the top researchers in this field—discusses the of well-designed medical systems. This comes across "chain of evolution of events" and how mistakes can clearly in Marianne Paget's The Unity of Mistakes: A often be recognized as such only in the context of a Phenomenological Interpretation of Medical Work specific, dynamic, complicated situation (10). (12), published in 1988, which probed the psyche of physicians on this topic. Paget analyzes in-depth interviews with 40 physicians and explores how phy- The Quality Perspective sicians think about their mistakes, as well as the psychological turmoil that physicians go through as The link between the patient safety movement they confront them. The book demonstrates how and the older, better-estabiishcd quality improve- difficult and common serious mistakes are for phy- ment movement has often been uncertain: At times, sicians, how hard each physician works to avoid the two groups have seemed to be entirely unaware mistakes, and yet (although Paget herself does not of one another. Journalist Michael Millenson's make this point) how limited individual effort is. highly acclaimed book, Demanding Medical Excel- Almost everyone in medicine works hard to avoid lence (11), published in 1997, shows how the two mistakes, and there does not seem to be much more disciplines fit together. Quality, he argues, should be room for individual effort to improve matters. An thought of as providing patients with the best pos- alternative path to progress is needed. sible medical care, and this requires continual progress not only at the highest levels of medical performance but also in shoring up the reliability Medicine's Changing Approach to Error and consistency of our most routine and basic tasks. While the book targeted the general public, most of The first Annenberg meeting in 1996—^whieh fo- those who have read it have some connection with cused on error in medicine and brought together a medicine. wide variety of disciplines—was a watershed event. The problems of error in medicine are addressed Many of the chapter authors in Bogner's book, in- in the chapter "First Do No Harm," and then pre- cluding Leape, Helmreich, and Cook and Woods, vention strategies are covered in "Saving Lives, Bit presented their view of the error "elephant." For by Byte." Millenson begins by providing a history of the first time, error experts from all over the world, the study of iatrogenic injury. He correctly points from both inside and outside medicine, convened in out that substantial data have been available for one place to discuss this issue. Many of the leading years. However, the publication of the results of the experts who participated were from different disci- Harvard Medical Practice Study finally provided plines and had not previously met. such detailed, incontrovertible evidence that the is- In subsequent years, as those studying error ex- sue could no longer be ignored. In the prevention amined risk and latent error in medical systems by chapter, he argues that information technology using perspectives that were new to many, the short- could allow the provision of much safer care by comings of the current approaches became obvious. linking disparate sources of medical knowledge and Most of the technologies and ways we do things in bringing them to clinicians at the time that chni- medicine were never designed with human limita- cians need them. In particular, he puts special em- tions in mind. Indeed, most medical processes were phasis on routinely incorporating outcomes data. At never consciously designed at all; rather, they were times, Millenson can be too strident, and he does built with a series of makeshift patches. Few such not get everything right—for example, he errone- processes in medicine would not benefit from a ously states that the Centers for Disease Control substantial overhaul. and Prevention has no definitions for iatrogenic in- fections— but this is perhaps the most readable, thorough discussion of the quality revolution in the Effective Prevention Strategies popular press, and it should be required reading for physicians. Early on, drug errors were identified as the most common type of medical error, and numerous re- search groups have since succeeded in redesigning Physicians' Reactions to Errors hospital pharmacy ordering and dispensing systems to markedly reduce in the incidence of drug errors. Much of the new paradigm is far off from the For example, implementation of unit dosing re- way physicians usually manage error. Traditionally, duced the frequency of medication errors by 82% in physicians have had a fierce ethic of personal re- one study (13). More recently, computerized physi- sponsibility, seeing conscientiousness as the key at- cian order entry—in which physicians enter pre- tribute of a good physician and good medicine—not scriptions online, where they can be checked for 764 2 May 2000 • Annals of Internal Medicine • Volume 132 • Number 9 problems—^was shown in a randomized trial to de- recently, the National Patient Safety Partnership crease the frequency of serious medication errors by was established, which includes both government 55% (14).

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