6 TheRecord OCTOBER 15, 2004 Current Research John McCain Meets CU Football Team Understanding and Preventing Medical Errors By Matthew Dougherty he headlines are shocking: dent, a faculty doctor and a stu- MEDICAL ERRORS KILL TENS dent and found that although the OF THOUSANDS ANNUALLY expert—the faculty doctor—made OR HOSPITAL DEATHS FROM errors, he corrected them more TMEDICAL ERRORS 195,000 PER YEAR. quickly than the resident or the stu- The National Academy of Sciences’ dent. The expert also immediately Institute of Medicine found in a corrected significant, life-threaten- 1999 study that 44,000 to 98,000 ing errors but left less important Americans die each year from med- ones to be corrected later.The resi- ical errors.Vimla Patel, professor of dent corrected a mix of serious and biomedical informatics and psychi- minor errors.The student corrected atry at Columbia University the least number of errors. Medical Center (CUMC), and her The pilot study showed that colleagues are conducting research experts make as many errors as to understand how these errors nonexperts, but the errors differ in happen and determine ways to pre- nature. “A good expert tends to vent them. manage errors and fix them quick- Her research collaborators ly, before serious problems can credit: Eileen Barroso include Desmond Jordan, associate develop,” Patel says. “Others don’t enator John McCain (R-Ariz.) The Arizona senator explained the At one point in his talk, McCain professor of clinical anesthesiolo- know they’ve made a mistake. By addressed the Columbia wisdom he acquired in five and a half sang the Columbia fight song, gy and lead anesthesiologist for the time they recognize an action football team for 20 minutes years as a prisoner of war in Vietnam. Roar Lion Roar, word-for-word. He the team that recently treated for- as a mistake, it’s too late.” Sin Mathematics Hall prior to “I really learned the meaning of added that he was required to learn mer President Bill Clinton during The researchers want to deter- the Lions’ recent departure to friendship and camaraderie” he said. each opponent’s fight song when his bypass surgery. Other mine which factors—stress, under- Bucknell University. McCain spent three years in soli- he attended the U.S. Naval researchers are Carlos Almeida, staffing, lack of knowledge or McCain, a 2000 Republican pres- tary confinement and said that he Academy. director of psychiatric emergency overtaxing a provider’s memory, idential candidate, spoke of the and his fellow prisoners had to Head Football Coach Bob Shoop services; Robert Green, assistant among others—push health care importance of communication and develop a system of tapping to arranged the address with a call to professor of clinical medicine and providers to make mistakes. With relying on teammates, noting, “The communicate with each other. the senator, whose daughter is a associate director of emergency identified stressors, the critical whole is a whole lot larger than the Their teamwork, he said, encour- sophomore at Columbia. services; and Edward Shortliffe, care environment could be better sum of its parts.” aged them to persevere. professor and chairman of bio- managed, physicians could be medical informatics. Their trained differently or technology research focuses on how decisions could be employed to reduce Kluge continued from page 1 are made in critical care settings errors. Doctors, nurses and hospi- and is conducted in concert with tal staff could develop better ways scientists at University of Texas of working together to anticipate School of Health Information and prevent an error or correct it Sciences in Houston. before it adversely affects a “I don’t think medical errors patient. The research could also can be eliminated entirely because prove useful in designing medical there is always some human error, devices that might prevent a but the number and severity of health care worker from giving the mistakes can be reduced,” Patel wrong medication or dosage to a says.“We study the whole picture patient. or process, which is messy but “You can’t simply identify real.Then we do a deep analysis of errors and try to reduce them,” the underlying reasoning used in Patel says. “That approach won’t making decisions about patient change anything significantly care.” because you don’t necessarily Patel’s research, funded in part understand the root causes of the by the National Library of mistakes. Mistakes are inevitable, Medicine, is an expansion of a but you have to learn to manage pilot study that analyzed activity them.” during a 24-hour period in the CUMC intensive care unit last year. Reprinted from In Vivo. She studied the actions of a resi- credit: Eileen Barroso “If I can help disadvantaged stu- would have been just another WGAY, in Maryland, and then Nobel continued from page 1 dents to experience the sense of a Cleveland kid working full time acquired other radio stations, inde- common enterprise and shared and going to community college,” pendent television stations and impossible until the receptors Center for Neurobiology and dreams that I knew as an under- said Young. “[Kluge’s] willingness syndicated rights to television responsible for picking up odor Behavior. “That’s a sharp distinc- graduate, then everything we to invest in human potential, that shows and movies.Metromedia,the molecules were identified. In tion to the three genes that the accomplish will be more worth- commitment to leveling the eco- company he built, grew into the 1988, Buck, working in Axel’s lab, visual system uses to discriminate while.” nomic and racial playing field, largest independent television busi- started tracking them down. several hundred different hues. It The Kluge Scholars Program helped me reach my goals and lies ness in the United States and diver- Several initial attempts failed. shows that a system like the visual provides 40–60 four-year scholar- at the very core of who I am as an sified into many other areas,includ- “Linda was an extremely cre- system is inadequate to distin- ships to students in need in each activist, teacher and researcher.” ing telecommunications. ative and tenacious fel- guish among the rich vari- incoming class, but “access to One cannot apply for an under- In 1986, Kluge sold his televi- low,” Axel says. “The ety of odors in the Columbia is just part of what the graduate Kluge scholarship; admis- sion interests to Rupert Murdoch solution to this environment.” Kluge program provides,” noted sions officers choose Kluge and became more involved with problem took The question Austin Quigley, Dean of the Scholars after the incoming class philanthropy.In addition to endow- quite a long now,Axel says, is, College. The program also enables has been selected.The merit-based ing the Kluge Scholars Program, time, but the How do our per- extensive programming aimed at award is offered to select students Kluge has contributed generously thoughtful- ceptions of the achieving goals of intellectual from underrepresented popula- to the Library of Congress, where ness of her ap- external world, growth, leadership development tions who the admissions officers he formed the James Madison proach made including smell, and global awareness. deem most able to benefit from Council, a private sector advisory me think she impact our emo- “Columbia would not be the being part of the community of board. He also founded the Kluge would eventual- tions and our great institution it is today were it scholars and who will in turn Center, which supports scholars, ly succeed.” behavior? not for John Kluge,” said President uniquely contribute to their and helped fund the National In 1991, Axel and “That is probably Lee C. Bollinger. “Like their name- cohorts’ experience at Columbia. Digital Library project, which Buck broke the field the most fascinating sake, Kluge Scholars are making Born in 1914 in Chemnitz, brings the library’s educational open when they published problem, and it will be their mark in every corner of the Germany, Kluge came to this coun- resources to remote locations. a paper describing an enormous extremely important in thinking world.” try at 8, grew up in Detroit and “To me,philanthropy comes nat- family of genes in mice that coded about diseases like schizophrenia One who came back to honor won a scholarship that allowed urally because I know that when for 1000 different receptors. Later to understand how the brain her benefactor was Cynthia Young, him to attend the College. After you pass out of this picture, you work revealed about 350 function- works” he says.“To know that the CC’91, who graduated magna cum graduation, he worked in a printing don’t take anything with you,” laude and is an assistant professor company, served in the Army dur- Kluge says.“With the sands of time, al receptor genes in humans. world is interested in our work of English and American studies ing World War II and then became a we make very little difference, but “We were quite surprised that will, I think, intensify our efforts and ethnicity at the University of broadcasting entrepreneur. He what difference we can make we up to five percent of the genome toward reaching an answer.” Southern California. “If I had not gradually acquired media outlets, should try to make.” was taken up by odor receptors,” received a Kluge scholarship, I starting with a single radio station, says Axel,a member of Columbia’s.