An error about mistakes

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There are few neurologists I admire more than Martin Samuels, chief of service at Brigham and Women’s Hospital in Boston.  So it truly pains me to see him engaging in a convoluted approach to the issue of mistakes.  Read the whole thing and then come back and see what you think about the excerpts I’ve chosen:

The current medical culture is obsessed with perfect replication and avoidance of error. This stemmed from the 1999 alarmist report of the National Academy of Medicine, entitled “To Err is Human,” in which the absurd conclusion was propagated that more patients died from medical errors than from breast cancer, heart disease and stroke combined; now updated by The National Academy of Medicine’s (formerly the IOM) new white paper on the epidemic of diagnostic error.

No, the obsession, if there is an obsession, is not about perfect replication and avoidance of error.  The focus is on determining the causes of preventable harm and applying the scientific method to design experiments to obviate the causes.  The plan is, to the extent practicable, implement strategies to help avoid such harm.

[T]here is actually no convincing evidence that studying these mistakes and using various contrivances to focus on them, reduces their frequency whatsoever.

Yes, there is convincing evidence (from Peter Pronovost’s work on central line protocols, for example) that the frequency of errors that lead to preventable harm can be dramatically, and sustainably, reduced.

For example, there is absolutely no reason to believe that a comprehensive medical record will reduce the frequency of cognitive errors, whereas it is evident that efforts to populate this type of record can remove the doctor’s focus from the patient and place it on the device.  

Well, here’s one place we agree! EHRs might actually increase the chance of cognitive errors. But why would you pick that one example, Martin?

We all try to avoid errors but none of us will succeed. This is fortunate as errors are the only road to progress. Focusing on the evil of errors takes our attention away from the real enemy, which is illness. We should relax and enjoy the fact that we are lucky enough to be doctors. 

There are errors that lead to progress and there are errors that lead to death and other harm. The flaw in Martin’s article is not so much what he says, as the extrapolation he makes from what he says.  A friend sent me a note summarizing the case nicely:

While I agree that we’ll probably never achieve zero errors in healthcare for a number of valid reasons, there is ample evidence that a systematic approach based on the scientific method can significantly reduce harm to patients.  Yet, there is no reference to the great work done by so many of his colleagues, e.g., Peter Pronovost, Lucian Leape, Donald Berwick, John Toussaint, Robert Wachter and Gary Kaplan, just to name a few.  Nor is there any empathy toward the patient and the impact of avoidable harm on his or her life.