Ah ne’er so dire a Thirst of Glory boast,
Nor in the Critick let the Man be lost!
Good-Nature and Good-Sense must ever join;
To err is human, to forgive divine.
This is an excerpt from An Essay on Criticism by Alexander Pope, arguably the greatest English poet of the 18th century. Much regarding this literary work has been forgotten over the years save for the line “…to err is human, to forgive divine.” However, man’s tendency to err and teachings concerning such date back to the 1st century AD. Seneca the Younger, tutor and later advisor to the Roman emperor Nero, advised “…errare humanum est perseverare diabolicum” – translated as “to err is human; to persist is of the Devil.”
Neither of these eloquent and revered individuals could have possibly imagined some of the catastrophic injuries that occur in modern medicine. Try using this cliche with family members of someone who just had the wrong leg amputated or who died because of the errant administration of another patient’s medication! There are lots of hospital protocols and interventions geared toward the reduction of preventable medical errors, and yet, they still occur. Medical malpractice lives on at an alarming rate.
In 1999, the Institute of Medicine (IOM) published a report entitled To Err is Human that addressed the issues of hospital and medical errors. This study of the IOM reported an estimated potential of 98,000 deaths annually due to medical errors. The report went further identifying the major sources of medical error which, by category, are listed as diagnosis-related, treatment-related, prevention-related and others, such as communication, faulty equipment and other system-related failures. It also offered strategies to alter the number of medical errors that were incorporated by most healthcare systems and national organizations.
The Joint Commission (also known as JCAHO) was established as a national organization in 1910 in order to improve healthcare facilities and promote these facilities to offer the safest and highest value of care to the public. This Commission has morphed and grown over the years, becoming involved in the monitoring and accreditation of all types of healthcare facilities and establishing sentinel event reporting strategies to track medical errors. In 2003, the Joint Commission announced a Universal Protocol™ for preventing wrong site, wrong procedure, wrong person surgery, effective July 1, 2004. This protocol specified pre-procedural verification, surgical marking of the operative body part, and the calling of a “time-out” prior to procedure initiation to confirm all of the details of the procedure with all those present along with verification of the patient.
Philip Stahel, M.D., et. al., in the October 2010 edition of the Archives of Surgery medical journal reported eye-opening details in a study geared toward determining “…the frequency, root cause and outcome of wrong-site and wrong-patient procedures in the era of the Universal Protocol.” A medical malpractice insurance company’s database was analyzed between January 1, 2002 and June 1, 2008, for physician-reported events or adverse outcomes in the state of Colorado. There were a total of 27,370 reported events during this 6 1/2 year period. Of these events, 25 were noted to have operations performed on the wrong patient; 107 events involved operations on the wrong body part; 25% of the events caused significant harm with one death from a wrong-sided chest tube insertion.
Colorado is only one state in the Union; it’s largest city is home to just over a half-million people. Compare and contrast this to New York City, which is home to over 8 million people. Medical care and medical facilities reflect the need of the population. Given that varying cities have varying populations and needs for medical services, a conservative estimate of national adverse medical events during that same 6 1/2 year period would simply involve multiplying the Colorado results by 50 (for 50 states). That would lead us to the following extrapolated statistics: 1,368,500 events; 1,250 wrong-patient surgeries; and, 5,350 wrong-body-part surgeries!
So, one wonders how all of these medical errors are continuing to occur when there are protocols in place to prevent such errors. Well, Dr. Stahel’s study looked at some of the determining factors. According to his research and analysis, the Universal Protocol’s issuance of a “time-out” was not followed in 72% of the errant cases. There were other contributing factors and providers that contributed to the medical errors, including non-surgical medical specialists, such as Internal Medicine and Family Practice physicians. WebMD also reported on this study identifying that judgement errors and communication errors were significant causes of medical mistakes.
As a medical reviewer in various capacities for the past 7 years, it is abundantly clear to me that medical charts are full of “right” and “left” errors in designation, with various providers for the same patient writing conflicting appendage designation in the same chart! Sub-specialty medicine also contributes to the quandry of patient care; there is often little communication between the multitude of providers caring for the very same patient on a daily basis other than what might or might not be written in the patient chart; legibility of the written word also plays a major role (Try deciphering some of the notes in a medical record just once!); lastly, and I’m going to go there, is the ego and attitude of some physicians/surgeons. The majority of surgeries performed in the USA are non-emergent or elective, so there is absolutely no excuse for any surgeon to ignore the Universal Protocol; yet, in 72% of the cases reported by Dr. Stahel, this was the case! Hopefully, electronic medical records will improve both communication amongst the various providers and legibility issues, but I have seen problems with these records; they still require that a provider make the effort to access the records in conjunction with his or her own patient assessment.
Granted, physicians and other medical providers are human, and humans are prone to err. Our system will never erradicate 100% of the errors, but the currently reported numbers are extraordinary and do not reflect adherance to medical standards and protocols – they scream medical malpractice. All physicians and medical providers should be held accountable to these standards and protocols simply because of man’s innate propensity to err; they are protective and proactive in an attempt to provide the safest and highest quality of care. In this case, ignorance is NOT bliss!
The divine quality of forgiveness will never compensate for the loss of a loved one, the significant loss of functional ability, the emotional and physical stress that errors can cause patients and their families, or the loss of economic and social contributions from a catastrophically iatrogenic (physician)-injured patient.