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
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
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
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
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.
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