Learning From Our Mistakes 10 Years After To Err Is Human

HealthLeaders Media Staff, December 2, 2009

As health providers recall the 10-year anniversary of the Institute of Medicine's celebrated wake-up call, "To Err Is Human," I flashed back to the story of Dan Jennings, a man I got to know fairly well.

Nearly 10 years ago, he was a "patient zero" of sorts in my horrifying education about avoidable harm. Bear with me while I tell this tale again.

Jennings, 47, traveled around the world teaching doctors about the diagnosis and treatment of sleep apnea. One day he got off a plane feeling severe pain in his stomach.

He went to his doctor, who admitted him to a Southern California hospital for surgery to repair a common bowel problem. He was discharged a few days later. Piece of cake.

But the pain just wouldn't go away, he repeatedly complained. Even when he moved slightly, something felt horribly wrong. Lying on his back in a station wagon, he was driven back to the hospital about two weeks later for X-rays to determine why he just kept feeling worse.

"Please get off the table, because there's some sort of object on it," the technician told him after taking the first set of images. When the artifact still showed up on the film, the technician asked Jennings to change into another gown because there must have been something wrong with the gown.

By the third series, the technician hurried to phone Jennings' surgeon.

A 14-inch long by 2-inch wide metal retractor remained lodged inside his abdominal cavity, stretched out straight. When the retractor was finally removed on Oct. 3, 17 days after Jennings' surgery, necrotizing fasciitis infection, which sometimes occurs when human tissue is exposed to metal, had begun to plow through his intestines.

How ever did this happen, with so many people in the room, was never publicly explained. Hospital staff and physicians at first pointed fingers at each other.

Jennings' learned that his was the last surgery the surgeon had scheduled during a 14-hour-long day in the operating room.

With stories like this to haunt me, I asked Paul M. Schyve, MD, senior vice president of the Joint Commission, whether patient safety has improved in the last 10 years.

What key things have we learned?

Schyve, a two-decade commission veteran with a passion for avoiding harm, says the field of patient safety is handicapped by not having a baseline to measure. Even the IOM report was really based on educated guesses.

The important thing it accomplished, he says, was to draw attention to the fact that preventable deaths occurred, and that they were much more common than previously suspected.

"It's hard to improve anything if you don't recognize you have a problem," he says. Today, he says, "Hardly anybody would say there isn't a safety problem."

Schyve lists five changes that the Joint Commission has made that he and many others believe have significantly changed both the culture and the practice around healthcare to avoid medical errors.

1. A three-step universal protocol for performing invasive procedures, such as surgery, to avoid wrong site, wrong person, wrong patient procedures, is followed in almost every acute care setting today. These include:

  • a) Verifying in advance that the team has all the tools and information it needs.
  • b)Marking the surgical site in advance—with the patient if possible.
  • c)Taking time out to double check immediately before the procedure to verify the patient, the procedure and the site.

"Those who consciously follow these steps find that they've eliminated wrong procedure, wrong site, wrong patient surgeries. Has anything we've done like this eliminated all risks? The answer is no."

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