The death of 17-year-old Jesica Santillan after she mistakenly received incompatible organs during transplant surgery at Duke University Medical Center has heightened concerns among medical providers and patients about medical errors.
“All of us have been saddened and alarmed by the recent event that occurred at the Duke University Medical Center. The only positive outcome I can see from this tragedy is that it serves as a trigger for other transplant programs to re-evaluate their policies and procedures,” Darrell Campbell, University of Michigan Hospitals chief of clinical affairs and a chair on the Patient Safety Committee, said in a written statement. “Human error will always be with us, but it is our responsibility as a health system to put enough fail-safe mechanisms in place that errors are detected and remedied before serious harm is done.”
But many health officials say that this is an old problem that is just now getting the attention it deserves. In November 1999, the Institute of Medicine reported that between 44,000 and 98,000 Americans die each year as the result of medical errors in hospitals, making it the eighth-leading cause of death – placing it higher than motor vehicle accidents, breast cancer or AIDS.
“Most of the country became much more sensitive to the possibility of error after the report was released,” said Robert Winfield, director of University Health Service. “Whether the numbers are accurate or not, it shows that there is a substantial problem.”
Aside from the physical risks, medical errors also carry a high financial cost. The IOM report estimated that medical errors cost the nation around $37.6 billion each year and that about $17 billion of those costs are associated to preventable mistakes.
Most medical errors have had less to do with neglect on the part of the medical providers and more with failures within the health system itself, Winfield said. He said he felt doctors’ fatigue contributed to risks in the healthcare industry.
“I know transplant surgeons work incredibly long hours. If you’re sleep-deprived as a physician, you’re more likely to overlook things and make mistakes,” Winfield said.
Like any other profession, there is a learning curve for medical students, but healthcare providers said they felt that did not contribute substantially to medical errors. Naseer Ahmad, endocrinologist at Providence Hospital in Southfield, said he felt that healthcare providers at the lower level of the curve were more careful and more worried about making a mistake.
Ahmad said that poor handwriting is often the cause for medication mistakes. With many medications holding similar names, poor handwriting and error on the part of the pharmacist could have serious consequences.
Technology is being used to prevent such errors. Ahmad said there are laptops available on the floor where he works so that doctors can just click on a medication instead of having to write out a prescription.
Many hospitals are also starting to use electronic records so that medical information is accessible faster. Technology is also available so that the records come with prompts that will bring certain aspects of the records to the physician’s attention. For example, if a dosage of medication seems too high, a prompt will come up on the screen asking the healthcare provider to check the prescription.
The University Medical Center has already begun to use electronic records and University Health Services is looking to acquire the technology sometime in the next five years, Winfield said.
“No profession is mistake-free, but in medicine the risks are more costly,” Ahmad said. “We are trying all the time to minimize these risks.”