People accept it as fact: that to err is human. Every misstep is an opportunity to learn and improve.
But when the mistakes are made by doctors, lives can be compromised, or even lost. Among malpractice claims, about 30% are due to diagnostic errors, according to a report by Coverys, a malpractice services provider. In the U.S. in 2017, surgeons either operated on the wrong patient, the wrong site or performed the wrong procedure 95 times, according to the Joint Commission, which accredits and certifies many healthcare systems in the country.
To Err is Human, a new documentary from 3759 Films and Tall Tale Productions that’s now available on Amazon and iTunes, explores the tragic outcomes of medical errors and the medical culture that allows them to persist. The film follows the Sheridans, a family from Boise, Idaho on their journey to understand how two major medical errors befell their family: one that contributed to a case of cerebral palsy, and another that involved a delayed cancer diagnosis and ended in death.
Many problems contribute to medical errors, the documentary finds, from fatigue of medical staff due to overwork and grueling shifts, to poor communication among employees in hospitals, to a culture in health care that often does not accept accountability for mistakes. Sue Sheridan describes how her first child, Cal, was jaundiced as a newborn, but since many newborns have some amount of jaundice, doctors didn’t take it seriously and discharged her son without running appropriate tests. She and her husband Pat later learned that Cal had high levels of a yellow chemical compound, called bilirubin, that contributed to brain damage leading to his cerebral palsy.
Years later, Pat had a lesion in his neck removed that the Sheridans were told was benign; they later found that a pathology report indicating that it was malignant was either not placed in his medical record or not seen by his doctor. The cancer spread and took Pat’s life.
Determining why medical mistakes continue to happen is critical to reducing their number. Studies have found that 69% of hospital-acquired infections can be prevented, and that hand washing can lower the spread of hospital infections — but staff still don’t always wash their hands between patients. And despite the fact that communicating information about patients is critical as shifts change, some essential pieces of information still aren’t conveyed, or are miscommunicated or misunderstood during shift changes.
Acknowledging mistakes, and therefore correcting and preventing them, is also particularly difficult in the medical community. “We built [the system] completely wrong,” says Dr. Don Berwick, former administrator of the Centers for Medicare & Medicaid Services and president emeritus at the Institute for Healthcare Improvement, in the film. “I was trained that no, you don’t talk about your mistakes with the patient — that’s liability.”
When the Sheridans discovered Pat’s delayed diagnosis, Sue says, “we expected the hospital to fully describe to us what happened, to take care of us. We were discharged without any explanation. We left there with all the documents in our hands with absolutely no explanation that this was an error. Our first reaction was fear. We were scared. It scared us that a hospital, a well-known hospital with professionals, would intentionally cover up that kind information.”
This lack of transparency and accountability has been the norm rather than the exception in medicine, experts say. In the film, Dr. Ashish Jha, a professor of medicine and healthcare at Harvard Medical School, admits to prescribing medication to the wrong patient after confusing him with another with a similar name. “I felt terrible, I felt incompetent, I felt a little ashamed,” he says. “My first instinct was not just to fix the problem, but not to tell anybody.”
“It’s clearly not the right thing,” Jha says, “but we have to begin by acknowledging that it’s a very human response.”
To protect patients from medical errors — and to make mistakes more transparent when they do happen — will involve changing the the paternalistic doctor-patient relationship and creating new systems. The documentary explores a number of strategies that are starting, glacially, to break down the barrier that keeps medical errors hidden. “One way to [reduce errors] would be to design the work environment not necessarily to prevent the error but to assume the error,” says Boaz Keysar, professor of psychology at the University of Chicago, who studies how information is miscommunicated when people interact with one another.
To address safety issues, medical experts are looking to the aviation industry, which serves as a model for designing programs to detect and reduce sources of life-threatening errors. Inspired by the black box that now travels in the tail of every commercial flight, in 2012 Dr. Teodor Grantcharov, professor of surgery at the University of Toronto, teamed with computer specialists to develop a black box for the operating room. He opened himself up to complete supervision by cameras placed throughout his OR; trained analysts log his team’s every movement before, during and after the surgery. The analysts and cameras record and monitor hand washes, the number of times the OR doors open, the details of how the surgeon and his team perform the procedure and more. The black box captures technical errors — if the surgeon suturing the patient fails to keep the needle in view on the display screens throughout the procedure, for example, or lapses in communication between the members of the team. Breaking down an operation in this way can isolate the sources of errors and help the surgical team to address them so that they don’t happen again.
Hospitals are also training doctors to be more transparent with their patients when they do make mistakes. Some now use simulations with actors to help physicians learn how to take accountability for everything they do, even when it results in negative outcomes. Checklists for medical staff, similar to the ones pilots and airline crew go through before each flight, are also helping doctors in emergency rooms, operating rooms and patient wards to lower the number of medical mistakes by making standard patient safety activities more routine.
“It’s a lot, it’s a ton,” says Berwick, of the number of mistakes that occur in patient care. “Our job is to make it zero. It’s urgent. It’s a public health emergency.”
