Avoiding Medical Mistakes

The New York Times on January 24 ran two sobering accounts of medicine gone awry. 

The more prominent, and by far scarier, was a chilling, front page article by Walt Bogdanich about two cancer patients who experienced horrible and eventually fatal adverse effects from messed up delivery of radiation therapy. 

The second, less visible episode appeared as part of a review of the book The Checklist Manifesto by surgeon Atul Gawande. The reviewer, cardiologist Sandeep Jauhar, included his recollection of watching placement of a central line catheter by a group of medical residents. 

central line catheter/image courtesy Chris Gregerson, http://www.lightstalkers.org

According to Dr. Jauhar, the residents had their sterile technique half right, dressing themselves in gowns and gloves and draping the patient’s upper body, but they erred by failing to also wear face shields and caps and neglecting to drape the patient’s lower body. The predictable result 2 days later: the central line became infected and had to come out. 

Dr. Jauhar’s review summarized the thesis of The Checklist Manifesto: A great way to avoid medical mistakes is to follow checklists. The contention by the author, Dr. Gawande of Brigham and Women’s Hospital, Boston,  is that medical failure occurs not so often from ignorance as from ineptitude: not properly applying what’s known to work, a practice that could be greatly aided by using checklists to ensure coverage of every important medical detail. 

A simple idea with the potential to save lives and cut nosocomial mistakes, but Dr. Jauhar voiced skepticism for widespread adoption. “Doctors resist checklists because we want to believe our profession is as much an art as a science,” he wrote in his review. 

He’s probably right, but I think there’s at least one other reason checklists will be slow to catch on: denial. Too often, I think, the feeling is that others make mistakes, not me. The accounts published today of botched radiation dosing and a compromised central line show that the stakes are way too high to avoid checklist safeguards. 

—Mitchel Zoler (on Twitter @mitchelzoler) 

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Filed under Health Policy, Hospital and Critical Care Medicine, IMNG, Practice Trends

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