Accounting for human flaws may bring fewer medical errors
In a just-released study, Johns Hopkins researchers raised this question:
Are patients dying from the care they’re getting, rather than from the disease for which they are seeking care?
The researchers report medical errors cause 251,000 deaths each year in the United States. That makes medical errors the third leading cause of death, just behind heart disease and cancer, and ahead of respiratory disease. But is that study giving us the entire picture?
Dr. Robin Hemphill, director of the Veterans Affairs’ National Center for Patient Safety, joined us on Stateside to discuss that question.
“At the end of the day, the healthcare system is very complicated,” she said. “There’s enormous handoffs, a huge amount of information, a fragmented healthcare system, so really ample opportunities for failures to occur.”
Because the system is so complicated, Hemphill said it isn’t easy to fix each part of the system. She suggested a more holistic route.
“So rather than imagining we’re going to fix one harm at a time, if we were to step back and say, ‘We need to understand that people are human and they will make human mistakes,’ -- especially when they try to interface with complexity, [and] a variety of patient needs that need to sometimes be unique, but other times be standardized -- as they’re trying to bring in and learn new procedures that can be lifesaving,” Hemphill said.
To conceptualize this idea, Hemphill pointed to the car industry. She said that industry understands that humans aren’t perfect – they make mistakes. That’s how seatbelts, airbags, rumble strips and guardrails came about.
"If we think about stepping back and designing things under the assumption that people are flawed, we might be getting to design things differently and that's a major culture change." - Dr. Robin Hemphill
She said the medical industry could have that same realization. It too could start accounting for imperfection.
“If we think about stepping back and designing things under the assumption that people are flawed, we might be getting to design things differently, and that’s a major culture change,” she said.
In that effort, Hemphill said it’s important to create what she called “a culture of safety,” where people are willing to talk about their mistakes and be accountable for them.
She also suggested a team approach, where patients and their families are partners in healthcare.
“As a family member and as a patient, you must be your own advocate in this system,” Hemphill said. “It’s complex. You cannot and should not assume that everything is going the way it’s supposed to. If it doesn’t make sense to you, ask. Speak up.”
She hopes someday the infrastructure and technology of the healthcare industry will make this team approach, which helps account for imperfection, more widespread.