Empower Patients

Medical Error as Medication Error: Systems Failure or a Doctor's Fault?

A patient is admitted to the hospital with 'complications.' Two doctors (specialists) separately prescribe medication causing "significant harm" when taken in combination. Is this medical error attributable to the specialists (medical malpractice), or is the error a systems failure?

It seems most today argue the error is a systems failure. I want to argue that the problem is not solely a systems problem. It is also a problem of culture, a problem deeply engrained in the culture of medicine as it is practiced today in the US, and as it is increasingly practiced around the world.

Let's first begin at the end of the chain with the occurrence of medical error and work our way back to the source of liability. The case study stipulates that a medical error has taken place in the form of medication error. The medication error is one of overuse, i.e., doctors (specialists) have separately prescribed two medications that cause significant harm when taken in combination.

Now, this is where the argument becomes complex, because it involves “miscommunication” coupled with a “failure to communicate.”

We presuppose that the patient in the case study consents to a prescription from each of the doctors (specialists) based on “incomplete information.” The “incomplete information,” in turn, is the result of a “lack of a unified diagnosis.”

Here is the source of the miscommunication: the patient believes he/she has “complete information” based on a “unified diagnosis” when he/she does not.

So, we begin with a “lack of a unified diagnosis” and work our way backward along the chain that leads forward to the end result, medical error in the form of medication error.

The question we must  address here is: What is the cause of the “lack of a unified diagnosis”? I believe this is where a “failure to communicate” becomes relevant in the case study.

Because the doctors (specialists) in the case do not communicate with one another, as a consequence, they do not coordinate their efforts in the care of the patient. Because they do not coordinate their efforts, the two specialists separately prescribe medications that are contraindicated causing significant harm to the patient.

So, now the question becomes, what is the cause(s) of the error. Is someone to blame; is it a “systems failure”; or something else in addition?

I propose we must first seek an answer to the question: What is the cause of a “failure to communicate”? Why don’t the doctors (specialists) coordinate their efforts?  Is that a systems problem?

A fragmentation of care (component management)—a doctor for every organ—is clearly a root cause. In the case, there is no “captain of the ship." Because no captain, no coordination; because no coordination, medication error as overuse.

Granted no 'captain,' still the question remains: Why don’t specialists talk to one another? Why don't they coordinate their efforts in the care of a patient?

I don’t think that efficiency of systems will of itself solve this problem. The problem involves issues of reimbursement, issues related to hospital politics, and, finally, issues related to the culture of medicine.

In specialization, med students are trained not to interfere with the work of other specialists. It’s simply the way medicine is practiced today in the US. Some call it episodic intervention: when something happens to an organ system, the patient sees a specialist in that organ system; when something happens to another organ system, the patient sees a specialist and subspecialist for that organ system, and so forth.

As a consequence, no one looks after the whole patient.

Unless and until we become willing to address systems issues, together with reimbursement issues, hospital politics, and the culture of contemporary medicine, patients/caregivers will continue to be forced to take on the job of "captain" of their own ship, a truly daunting task!

To end with an answer to the question, ultimately IMHO, the source of the medication error in the case study is the failure to communicate among doctors (specialists) in failing to coordinate their efforts in the care of the patient.

"SiCKO" Doesn't Go Far Enough! (Pt.2)

A perfect storm gathers at the hospital bedside for anyone who suffers the slightest ‘complication.’ Michael Moore missed an opportunity to track this storm in “SiCKO.” While he had a visual, he neglected the infrared view.

His insights into systemic problems enabled him to detect the consequences of the ‘medical model’ on the problem of access. However, the majority of Americans face a very different sort of crisis as a result of the ‘medical model.’ It is a crisis in the delivery of their health care at the hospital bedside. This crisis ultimately leads to the gross and widespread violation of our most basic patient/caregiver right: the right to informed consent.

As in any perfect storm, a simultaneous occurrence of specific events brings this one into being at the hospital bedside. Taken individually, each event might be of little consequence, but taken together they produce a hurricane of devastating magnitude that rips through the lives of countless patients, families and caregivers.

Moore shows us in “SiCKO” that, under the ‘medical model’, we reimburse doctors in this country based on the number of procedures they perform. However, Moore neglects to document the impact this reimbursement scheme has on the delivery of health care at the hospital bedside. Specialists multiply on a particular case based on referral, with no doctor wanting to interfere with a colleague’s ability to make money.

Quite simply, doctors compete for those finite reimbursement dollars. Each needs to perform some procedure on the same patient in order to get paid.

Reimbursement works in consort with other events to create our perfect storm. Over the course of the last twenty years, component management has emerged as the standard of care in medicine, entailing ‘a doctor for every organ’.

Naturally, we want people to specialize. No one would argue that the application of science to medicine has produced enormous advances. However, we also need specialists to coordinate their efforts in the care of individual patients.

This has not happened. Instead, patients and their caregivers experience ‘episodic intervention’, another element in the perfect storm: when something happens to one organ, the patient sees a specialist in that organ system based on referral; when something happens to another organ, the patient will see another specialist and subspecialist for that organ system, and so on.

Episodic intervention leads unavoidably to fragmentation and a lack of coordination among specialists in patient care—care that lacks continuity for both patients and their caregivers.

The perfect storm gathers speed as fragmentation and a lack of coordination result in a breakdown in communication among doctors and between doctors and patients/families/caregivers. With no one to care for the whole patient, family members or caregivers are left to their own devices to somehow integrate the care of their loved ones.

They struggle against gale force winds to piece together bits of information from different specialists and subspecialists in an attempt to get a complete picture of what’s happening to their loved one.

As the hurricane makes landfall, this perfect storm leaves devastating consequences in its wake. The initial storm surge in the form of a breakdown in communication leads first to conflict.

Because doctors don’t talk to one another over patient care, they invariably end up arguing, usually in the chart. Pressure builds as the hurricane circles over the lives of patients and their caregivers. In a second storm surge, the conflict among doctors then leads to conflict between the “team” and patients/caregivers, as they attempt to brace against the gross violation of their right to informed consent.

The eyewall in the middle of our perfect storm is clearly medical error. Doctors don’t talk, they fight, and their failure to communicate causes medical error. As many as 250,000 people a year die as a consequence of medical error according to a recent study done at John Hopkins, making medical error the 3^rd leading cause of death in the US, well ahead of motor vehicle accidents.

In short, Moore missed an opportunity to track the perfect storm that exists in the delivery of health care at the hospital bedside in this country. Silos harden through a scheme for reimbursement that incentivizes component management and episodic intervention to create fragmentation and a lack of coordination, which leads to a failure to communicate, a gross violation of patient rights, conflict and, ultimately, to medical error.

At 250,000 deaths a year, this crisis clearly dwarfs the problems of wait times or the amenable mortality rate associated with a lack of access.

"SiCKO" Doesn't Go Far Enough!

The only possible authentic criticism of Michael Moore’s “SiCKO” is that the movie doesn’t go far enough from a patient rights perspective. We can’t blame Moore for this; he simply doesn’t have the requisite experience in hospital-based patient care. However, he could have used his insights into systemic problems to drill down to the hospital bedside in exposing another crisis patients/families face everyday in the delivery of their health care.

Moore makes a critical distinction between the ‘medical model’ and the ‘social model of medicine.’ Under a social model of medicine, a health care system rewards doctors based on the health of their patient populations. Every other industrialized nation uses a social model of medicine. By contrast, Moore notes the US health care system uses a ‘medical model.’ Under this regime, the system reimburses doctors based on the number of procedures they perform.

Moore uses this important distinction to underscore problems of access. When a health care system incentivizes doctors to keep a patient population healthy, patients in that population naturally have ready access. In the US, while doctors have the financial incentive to perform more procedures, insurance companies are motivated to limit the number to increase profit. Moore documents brilliantly how US citizens are caught in the middle of this epic struggle between doctors and insurance companies to make money.

Moore chooses to focus primarily on ‘denial of access’ as a consequence of the medical model. Of course, this is quite understandable given the severity of the problem. However, it would have been very easy for him to have also exposed another consequence of the ‘medical model.’

It is a crisis more deadly than the access problem. It also has a greater impact on more US citizens.

Patient Empowerment and Conflict in End of Life Care

Ever hear the joke about “Chi Chi”? Dr. Mehmet Oz, internationally renowned cardiothorastic surgeon and Oprah’s health care guru, told me the joke during an interview on his show, the “Dr. Mehmet Oz Show,” on Oprah & Friends XM Radio 156. He used the joke as a metaphor for end of life care in medical decision making. It literally took my breath away.

The joke reads as follows: A hostile tribe captures two explorers. The tribesmen drag the explorers before their Chief.

The Chief asks the first explorer, “Death, or Chi Chi?” He obviously doesn’t want to die, so he responds, “Chi Chi!”

Three beefy tribesmen bludgeon him almost to death.

The Chief then turns to the second explorer and asks, “Death, or Chi Chi?” He doesn’t want to suffer the same fate as his partner, so he responds, “Death!”

The chief then says, “Ok, but first Chi Chi.”

When Dr. Oz told the joke, I almost fell of my chair because of the truth he spoke about medical decision making at the end of life in a hospital setting. I’m lucky I had the wherewithal to finish the interview! The joke illustrates perfectly in metaphorical terms how a lot of people die in this country in hospitals. No one talks about it, but this is commonplace in end of life care in the US health care system.

At some point in a patient’s trajectory at the end of life, a dignified death might have been possible. Instead, like the Chief, the doctors on the patient’s healthcare “team” say, “Ok, but first Chi Chi.” In Dr. Oz’s words, they then proceed to torture the patient’s body over the course of the final two weeks of life!

In my opinion, the issues of reimbursement in health care delivery and fragmentation in patient care rear their ugly heads yet again. This time in relation to end of life care.

In the US health care system, we reimburse doctors based on the number of procedures they perform. Component management is the standard of hospital care, with “a doctor for every organ.” Consequently, in hospital care, if something happens to one organ, you see a specialist for that organ; if something happens to another organ, you see a specialist and subspecialist for that organ, and so on. Specialists multiply on a particular case based on referral, and no doctor wants to interfere with another doctor’s ability to make money. Quite simply, doctors compete for finite reimbursement dollars.

As a result, no one looks after the whole patient!

I have witnessed time and again a typical scenario in end of life Patient Care Conferences: one doctor argues with the other doctors on the healthcare  “team” about how “his” organ is in good shape— it just needs a bit more time to ‘get over the hump’. Every other specialist on the “team” argues the very same thing about their respective organs.

Meanwhile, family members remain in a state of bewilderment. No one seems willing to tell them what’s going on with the whole patient. They are left largely to their own devices to somehow piece together bits of information from each specialist and subspecialist in an attempt to get a complete picture of what’s happening to their loved one.

Time passes as doctors continue to perform their Chi Chi on the patient.

Dr. Oz and I agreed, a network of relationships with key hospital personnel is the only way caregivers, family members or patient advocates can empower themselves to think clearly and act in the best interests of the patient. Patient empowerment and caregiver issues can only be addressed through relationships and not simply by the use of electronic medical records.

Chief Cause of Patient Rights Violations: The Fragmentation of Health Care Delivery

What can we learn from the National Institute for Patient Rights survey of the top ten violations of patient rights? What's the take away?

We learned that, despite billions spent on advanced medical technologies such as drugs and devices, patients daily experience an erosion of their most fundamental rights. The rights of patient self-determination and informed consent seem to suffer most.

We also learned that, the number one cause of this gross and widespread violation of patient rights is fragmentation in healthcare delivery, or a lack of coordination among specialists in patient care.

Fragmentation leads to a breakdown in communication among specialists and between the "team" and patients/families, resulting in unnecessary conflict, patient rights violations, and, ultimately, medical error.

No one on the "team" seems willing to speak up on behalf of the whole patient, so patients and their families are left alone struggling to integrate their own care by piecing together bits of information from specialists in an attempt to get a complete picture of what's happening to their loved one.

So many people who took part in the survey complained about the inadequacy of multiple diagnoses coming from multiple providers. Without a single, complete diagnosis, respondents felt unable to make an informed choice about appropriate treatment options.

This is simply reprehensible from an ethical point of view!

What's the chief cause of this state for affairs? One word: economics.

In this country, we reimburse doctors based on the number of procedures they perform. Quite simply, doctors compete for finite reimbursement dollars. Specialists multiply on a particular case based on referral, and no one wants to interfere with the other's ability to make money.

However, even if we managed to some how eliminate the politics and economics from the delivery of care at the bedside, we would still be stuck with the consequences of component management, with a doctor for every organ.

Paradoxically, the widespread violation of patient rights in hospital-based care may be a direct consequence of the success of medicine, specifically of the application of science to medicine.

The scientific method lends itself to reductionism with researchers analyzing smaller and smaller parts. Likewise in the application of science to medicine, doctors become specialists, who confine their focus to individual organs; subspecialists focus even more narrowly on the parts of organs.

Under component management, doctors have become just so many research scientists.

Component management in turn lends itself to episodic intervention. The breakdown in communications due to a lack of coordination causes anger and frustration among patients and their families.

In addition, a failure to communicate causes unnecessary conflict. It also causes significant harm when patients suffer underuse, overuse, or misuse as a result of medical error.

It seems that, unless and until hospitals and their health care professionals adjust to the success of science in medicine, patients and their families are likely to continue to experience one or more of the top ten violations of patient rights.

The Violation of the Patient Right to Review Medical Records under HIPAA

Coming in at a close #10 in the National Institute for Patient Rights survey was the violation of the patient right to review their medical records and receive an accounting of disclosures regarding health information under HIPAA.

Many participants observed that they have moved frequently during their life times. Consequently, they have received medical care from various providers over time. Each provider keeps his or her records detailing visits and treatments. The same is true for hospitals, clinics, laboratories, pharmacies, and so on. One participant noted, “Like most people, I’ve moved around quite a bit. Over time, it’s easy to forget when you were treated, by whom and even for what!”

Respondents noted such problems as the wide variation among providers in the amount of time they retained records, paper records were misfiled or even destroyed, electronic records were lost, stolen, damaged or vulnerable to unauthorized access, and physicians sold their practices. Stated a respondent, “I was made to feel intimated in asking one of my doctors for a copy of my medical records. He acted like my medical record was his property and his only.”

Patient Rights Violations and Medical Error

Although listed at #9 in the new National Institute for Patient Rights survey, the violation of a patient/advocate’s right to know the identity and professional status of those who care for the patient contained some of the most poignant responses in our survey results. Some of the narrative statements were truly heartbreaking.

Fifteen percent of  participants claimed to have suffered some "significant harm" as a result of medical error. Eight-six percent of those said if they had had ready access to information about the identity and professional status of their providers, they would have had second thoughts about consenting to treatment.

Said one respondent, “I am permanently disabled because of what a doctor did to me. I found out only much later and through my lawyer the hospital knew the doctor caused similar problems in the past with other patients. Why didn’t they just tell me?!”

Hospitals' lack of transparency cause of the violation of patient rights

In the new National Institute for Patient Rights survey, conflict was also the cause of violations #6 and #7, violation of patient right to know hospital rules on charges and payment methods, and the patient right to review the hospital bill, have information explained, and get a copy of the bill. Said one respondent, “It was like pulling teeth to try to get an explanation of certain charges. I still don’t know why I was charged for things I know we didn’t use.”

Under violation #8, some participants complained about their inability to identify hospital personnel who could help in resolving discrepancies over billing issues or in disagreement between “team” and patient/advocate over treatment. Patients and their advocates have a right to know of hospital resources, such as patient complaints and grievance processes, patient representatives or ethics committees. It was common in the survey results for respondents to have expressed the desire to have known about the hospital ethics committees and their members in the event of conflict over treatment options.

Conflict between Doctors and their Patients as a Cause of Violation of Patient Rights

Conflict between “team” and patient/advocate was the cause of #5 on The List of the latest National Institute for Patient Rights survey. Patients and their advocates have a right to know of realistic care alternatives when hospital care is no longer appropriate. Some participants observed that no one ever approached them about realistic care alternatives in the event that hospital care was no longer appropriate.

Not only was there no discussion of alternative care options, but many respondents complained about how they were made to feel when they disagreed with providers about the continued appropriateness of hospital care. One respondent noted, “They made us feel like we were immoral when we questioned their treatment recommendations!”

Conflict was also the cause of violations #6 and #7, violations of a right to know hospital rules on charges and payment methods, and a right to review the hospital bill, have information explained, and get a copy of the bill. Said one respondent, “It was like pulling teeth to try to get an explanation of certain charges. I still don’t know why I was charged for things I know we didn’t use.”

Chief cause of the violation of patient rights: A failure to communicate

A failure to communicate is responsible for the #1 spot on the top ten list of most violated patient rights. A full 63% of participants felt that healthcare providers most often violated their right to informed consent. When prompted to explain, many complained about the inadequacy of multiple diagnoses coming from multiple providers. Without a single, complete diagnosis, respondents felt unable to make an informed choice about appropriate treatment options.

The #2 violation on the list is related to the same problem. Participants often complained about the way in which doctors presented them with treatment options. The following is a representative statement, “I felt as if I was in automobile show room and the salesman was presenting me with a list of options for a new car.”

The #2 most violated of patient rights was a lack of respect for personal, spiritual, and religious values and beliefs. Participants observed that many doctors do not seem to care about personal preferences. Consequently, they often failed to acknowledge the unique nature of personal lifestyles in their presentation of  treatment options. To quote one respondent, “I would have liked my doctor to have recommended a treatment option tailored to my love of the outdoors. He never even asked.”

A failure to communicate was also the cause of the #3 violation of patient rights, a lack of respect for advance directives. Participants complained vociferously about the way in which advance directives are handled by most hospitals. Stated one respondent, “The only time any one every mentioned my living will was at admissions. No one ever asked me again about my personal wishes.”

Miscommunication was the cause of violation #4. Despite HIPAA, many participants observed that providers often showed no regard for the privacy and confidentiality of their personal health information. Cell phones were often cited as the main culprit. Said one respondent, “A nurse bent over me to straighten out a line with a cell phone in her other hand, blurting out sensitive information about a patient in the next room. It was embarrassing!”