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Interview:
Robert Wachter: Minimizing Medical Mistakes

First published August 2004

Profile: Robert M. Wachter, a professor of medicine, chief of the medical service and chair of the patient safety committee at UCSF Medical Center, has long been known as a pioneer of the hospitalist movement. With the publication of Internal Bleeding: The Truth Behind America's Terrifying Epidemic of Medical Mistakes, he and coauthor Kaveh Shojania have earned fame as mavens of medical errors that kill an estimated 100,000 Americans each year.

Q: Do you think of yourself as an alarmist?

No, not at all -- if anything, I'm that oxymoronic "passionate moderate." I was a little worried that nurses, doctors, administrators and others in the hospital world might think so after reading the book -- so much so that I even tried to convince the publisher not to use the word "terrifying" in the subtitle. So far, though, the reaction to the book has been uniformly positive.

Q: What do you think about that word "terrifying" now?

I think it is probably the right word. Those of us who work in hospitals have really become inured to the frequency of errors, large and small, yet I've come to recognize that many patients really are terrified by the possibility of medical mistakes. But even though the subject scares them, people I think want answers as to why errors keep happening, particularly since so many people have personal experiences with errors themselves or in the care of a loved one.

Q: What explains the lack of a backlash to your book from the medical community?

We were very careful not to blame people, and instead try to show through our cases how it is that systems fail. Modern Western medicine is a marvel, after all, and we didn't want to suggest otherwise. Working in a place like UCSF, I see the miracles of what we can do for people nearly every day. But the errors are there, in every hospital, every day, and I think our profession has matured enough to accept that the only way we're going to fix it is by first admitting that we have a serious problem. The feedback we've gotten from around the country is that the cases and our analysis ring true. Some folks, including doctors and nurses from some of America's most prominent hospitals, have asked me whether I was hiding in one of their hospital rooms, since they've all seen errors like the ones we describe, even the ones that seem most outlandish and dramatic.

Q: You chose not to name any of the institutions where the mistakes occurred. Don't readers have a right to know?

The problems are everywhere. As soon as you say, "This happened at Hospital X" or "The doctor was Dr. Y," people invariably point fingers at that place and person and lose sight of the systems failures that are really responsible. Look at it this way -- ask anyone if they've seen a medical error and they'll immediately tell you a story about one. Could it possibly be that all doctors and nurses are careless and stupid? Or, perhaps, does the ubiquity of the problem indicate that something deeper and far more interesting is going on? So we focused on the latter.

Q: What is root cause analysis and how does it help uncover these systems failures you describe in your book?

Root cause analysis [RCA] is a technique to dissect out the systems failures that underlie most errors. It works by focusing on the process of care, not on who is to blame. In the book we give examples of what happened after 9/11 and the space-shuttle disasters, well-known examples of major systems breakdowns. In a root cause analysis we ask, "Why did this person act the way he did? or "How did this happen?" rather than simply, "Who is responsible?" Almost invariably, RCA points out problems in communication, rigid hierarchies, absence of redundancies and other systemic flaws that, if unfixed, are setups for continued errors. As we write: "Think of your doctors and nurses as actors in a grand play. Sure the play is different when King Lear is played by Sir Laurence Olivier versus Robin Williams. But Lear dies in both stagings. If we want the patient to live, we must change the script." A good RCA analyzes the script more than the actors and points the way to a safer rewrite.

Q: You also mention something called the Swiss cheese model for errors. How is that relevant to medical mistakes?

Small errors in a complex system like hospital care only reach patients when many holes in the safety barriers -- the layers of Swiss cheese -- align. The key point to remember is that this is a system where small mistakes, like a reversed X-ray, a typo on a surgical schedule, a smeared name on the nursing station whiteboard, miscommunication between doctors when a patient is handed off, can become catastrophic as they start to build up. Making things safer usually requires an understanding of both the layers of protection and their holes.

Q: As you say, the same is true of flying an airplane. Is that why you often hold up the airline industry as one that the medical industry would do well to emulate?

Airline pilots and doctors are both highly trained professionals operating in complex technological environments. But the cultures of our two fields have diverged in the past generation. In the 1950s, there was little safety culture in aviation and not much systems thinking. The early test pilots were swashbuckling, freewheeling individualists who had a blast. The problem was, they died like flies. Aviation today is far safer because trying to mint the flawless pilot was a fool's errand; it now emphasizes safety training and retraining, the use of checklists and readbacks, simplification and standardization and teamwork. Pilots have learned how to listen to their colleagues, and those lower in the hierarchy have learned the importance of speaking up when they have concerns. Physicians are largely stuck in the swashbuckling, go-it-alone mindset, and things won't get much safer until we begin adopting some of the lessons from aviation and other safer industries.

Of course, pilots have one hell of an incentive to create safer systems -- sitting in the front end of the plane, they die first. Lacking that incentive, the medical profession has focused more on progress and technology than on ways of delivering care safely. A colleague once asked me, "If instead of 100,000 patients in the US dying each year from medical errors, how different would the medical profession's approach have been if it were 100 doctors who died every year?" It's a startling question and, I think, a good one.

Q: Has the complexity of treatments and technology contributed to the number of medical mistakes?

Fifty years ago, medicine was pretty ineffective but it was also pretty safe. You had a single doctor -- a Marcus Welby -- there were only a handful of medications and tests, and it wasn't hard to keep track of everything and execute well. Today, all of that has changed. Care has become far more complex and specialized, which is generally a good thing. But for a generation we have operated under the illusion that medical progress equals medical safety. Not only is that not true, but I think they actually travel in opposite directions: As care gets more sophisticated, it also gets less safe, unless you're plowing as much energy into creating safer systems as you are in creating more complex, specialized ones.

That's not to say that all errors can be blamed on modernity. Technology will help to save us once we traverse a painful learning curve. How can it be that in 2004 -- and in the Bay Area of all places -- we rely on my rapidly failing memory to catch a potential drug interaction (when there are literally tens of thousands of potential interactions)? Part of the answer to all of this will be computerization of the prescribing process, decision support at the point of care, bar-coding, and so on. It's not the whole answer, but it certainly will be an important piece. I'm pleased to say that at the UCSF Medical Center, we're in the middle of a huge effort to computerize the entire clinical enterprise. The payoff will be immense.

Q: You are known as a pioneer of the hospitalist movement. Can you describe what it is that hospitalists do and whether they can make a difference in this epidemic of medical mistakes?

Hospitalists are hospital-based, generalist physicians who take charge of a patient's care from the moment they are admitted to the day they are discharged. There are a lot of people who play a role in inpatient care -- nurses, technicians, specialists, social workers, pharmacists, managers, etc. -- and it is the hospitalist's job to provide the continuity, to know his or her patient's case thoroughly, and to serve as the orchestra conductor and the patient's advocate. But a good hospitalist is even more than that. When we pioneered the hospitalist concept at UCSF, we had a once-in-a-lifetime opportunity to stamp a professional field with a new identity and purpose. So we have really pushed our hospitals, and those across the country, to not only focus on providing terrific care to individual patients but also to be leaders in making their hospital system work better. It's not coincidence that hospitalists so often emerge as the leaders in areas like patient safety and quality.

Q: Has the hospitalist concept caught on?

Yes, absolutely. In the eight years since Dr. Lee Goldman and I coined the term in the New England Journal of Medicine, we've gone from a handful of hospitalists to more than 10,000 in the US. At this rate of growth, there will be more hospitalists than cardiologists in a few years.

Q: Studies show that hospitalist care can save money, but is there hard evidence yet that it can actually cut down on medical mistakes?

A study by Andy Auerbach of our group showed a one-third lower mortality rate in a community hospitalist program. I have to think that some of the benefit was from fewer errors, or from catching errors before they could cause harm. Hospitalists are well-positioned to see where errors begin. One hospitalist, a former UCSF resident named Sanjay Saint, discovered that one-third of the doctors in his hospital didn't remember if they had ordered their patients' urinary catheter removed when it was no longer necessary -- an invitation to infection. So his hospital put a new procedure in place to automatically remove the catheter after a few days, and the rate of urinary tract infections plummeted. This may not seem very dramatic, but it is just one step in a bigger effort to instill a culture that prizes safety and focuses on systems solutions.

Q: Do you worry that by admitting errors, hospitals will trigger a wave of higher malpractice rates? And if so, is that one reason why medical errors persist?

Admitting errors is nothing new inside hospitals. People discuss them all the time in regular morbidity and mortality meetings. The malpractice system is a mess, but if malpractice insurance costs went away tomorrow, I don't think patients would be safer. Mistakes would still happen and we still don't have the right systems to catch them. No, the real reason we haven't fixed medical errors is that we haven't yet been able to make the business case for investing in safety systems. It makes sense that if you do everything that is necessary to keep patients safe, you will have happier providers and happier patients, and ultimately the system will run more efficiently and save money because you have fewer costly errors and fewer malpractice suits. But try to sell that concept in the average hospital when safety is pitted against the need for five new operating rooms or a new parking garage. I'm pleased to say that UCSF is ahead of the curve in terms of its commitment to these kinds of programs, but it is never an easy sell.

Q: What can patients do to help this change along?

On the book jacket, our new School of Medicine dean David Kessler wrote that Internal Bleeding is ER meets Fast Food Nation. I like that. The pressure will have to come from patients and then from purchasers, regulators and others to demand that hospitals focus on safety. Right now, would-be patients are more likely to compare cars than care. Hospital leaders need to feel that they will be rewarded in the marketplace by investing in safety and quality. And patients shouldn't be afraid of asking their doctors and hospitals, "What are you doing to keep me safe?" And once a patient is in the hospital, I think it does pay to be vigilant, to keep his or her eyes open, and to ask questions. But in the end, it shouldn't be the patients' responsibility to keep themselves safe. It must be ours. Creating a business case for safety is important, but the overwhelming consideration is that there is, and always will be, a moral case.

See also:

UCSF Today: Web-Based Journal Draws Patient Safety Lessons from Actual Cases

UCSF Today: UCSF Faculty Honored for Work in Patient Safety

UCSF Hospitalist Group

Robert Wachter
Robert Wachter. Photo by Kaz Tsuruta.

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