TEDMED: speaker calls for candor about medical errors

During her talk at TEDMED 2014, Danielle Ofri, MD, attending physician at Bellevue Hospital and associate professor at New York University School of Medicine, said it is time to rethink medical errors.

After finishing her medical training and practicing for 4 months as an emergency physician, Ofri missed a cranial hemorrhage in a patient showing signs of an “altered mental state” because she failed to look at his CT scan. It was a busy night, and she heard someone call out that the results of the CT were fine, so she went about her other business. Fortunately, someone else saw the scan and rushed the patient into treatment, making the case what Ofri calls a “near miss.” For 25 years, fear and shame kept her from telling anyone about the error. Ofri said the “toxic culture of perfection” is pervasive and is currently holding back progress in error reduction.

Ofri, author of the books What Doctors Feel, Medicine in Translation, Incidental Findings, and Singular Intimacies: Becoming a Doctor at Bellevue, said it is important for physicians to acknowledge medical errors, including the fact that errors will occur. But, she said, it is equally important for patients to understand.

“Error is intrinsic to normal human functioning,” Ofri said. “But, the expectation by doctors and patients is perfection.”

Patients often present with multiple comorbidities, so physicians have “thousands of microdecisions to make” about providing care, including how to treat their illnesses or any pain they may have, as well as address costs and what insurance may or may not cover. On top of that, she said, patients may have financial worries, concerns about an aging parent, history of heavy alcohol use or unsafe sex, a poor diet and other risks to their health that may need to be addressed. The physician also must consider what preventive screenings, such as mammography or colonoscopy, may be appropriate. The large number of decisions a physician must make each day, even if 95% or 99% of those decisions are on track, puts them at risk for dozens of errors.

“To eradicate error, medicine has been told to take a page from the aviation industry. We have adopted some of those tactics, like checklists before surgeries, barcodes on patient beds, system fixes for lookalike medicines, but these are the low-hanging fruit. The vast majority of errors never come to light. How can we fix them if we don’t know where they are?”

Ofri said the key to changing the system is to reduce the feelings of fear and shame surrounding medical errors so that physicians and nurses feel more comfortable speaking out when errors occur.

“We need to be intrepid enough to face this honestly. A good start might be for the top brass [at hospitals or other medical institutions] to speak openly about their medical errors, especially to doctors in training, but also to the public. If we hear that errors are a reality in medicine, no matter how good we are or how good our systems are, we might be able to redefine our ideal of perfection,” Ofri said. “We need the emotional courage to admit vulnerability.”

The emotional aspect of error needs to be recognized and addressed as part of the improvement process, according to Ofri. She also said a better system of compensation for those who suffer at the hands of medical errors would be no-fault compensation, or something similar to the vaccine injury compensation program, rather than the more common use of malpractice lawsuits.

“Patients — that means all of us — have a vested interest in these errors coming to light,” she said. “The best disinfectant is sunlight.”

For more information:

Ofri D. Presented at: TEDMED 2014; Sept. 10-12, Washington, D.C.