As evidence shows that many patients are harmed by healthcare, we must think of new ways to provide care that is both safe and humane.
I became a doctor because I wanted to help people; a cliche but true. I wanted to diagnose diseases, offer treatments and in some small way relieve suffering. It seemed almost perverse to think that I might be contributing to harms when I wanted to do the exact opposite. Surely incurable cancers or catastrophic injuries were much more of a problem than my own best efforts at practising medicine.
But the evidence shows that healthcare related harms are real, and costly. In the USA medical malpractice alone is estimated to cost over $55 billion a year (1) and in the UK £2.4 billion was paid out for clinical negligence claims in 2018, with the prospect of this increasing rapidly over the coming years (2) (3). The WHO estimates that one in ten patients are harmed while receiving hospital care, and that many of these injuries are preventable (4).
These numbers are startling, but they don’t tell the whole story. Behind these figures are children left disabled for life, or families grieving a sudden death that should never have happened. Imagine for a moment the sheer horror of being told that your spouse, parent or child who you thought was in the safe hands of caring professionals had somehow been left harmed or even killed by some avoidable mistake.
While the impact on patients and their families is enormous, the possibility of making a mistake also takes a real toll on healthcare professionals. I have spent countless sleepless nights worrying about a decision I made; I have come back into work on days off because I couldn’t stop thinking about a patient I’d seen the previous day; I have called the hospital ward in the middle of the night worrying about a prescription that I might not have completed. And almost every doctor I know has similar stories.
And yet mistakes are inevitable. While we like to think of medicine as a dispassionate objective science, it is practiced by humans who are invariably fallible. And the number of mistakes is likely to increase in the future. Medicine today is more complicated than it has ever been; not so long ago a patient with a heart attack was advised to rest, take an aspirin, and hope for the best; but that same patient today might get an urgent angiography, receive a cocktail of drugs to protect the heart, and then a battery of tests as an outpatient. As our capacity to do good increases, so too does our capacity to cause harm — open-heart surgery comes with many more risks than bed-rest and the medical interventions of the future (such as gene editing or nano-therapy) will carry their own specific dangers to our patients.
It is not only medical knowledge that’s becoming more complicated, but patients themselves are as well. Thanks to the advances in modern medicine, many patients are now living longer than ever before. Many patients presenting to primary and secondary care are elderly, with a variety of different ailments, taking a variety of different pills. This multi-morbidity and poly-pharmacy dramatically increases the complexity of medical practice as any new symptom or intervention has the potential to set off a complex cascade of secondary effects that need to be carefully considered at the outset of any consultation.
As the overall environment around doctors becomes more and more complicated it’s almost inevitable that more mistakes will be made, either by omission (not ordering the test that would have made the diagnosis) or by direct harm (inappropatiely prescribing a drug which caused terrible side-effects).
In an effort to support ourselves, we have a developed an arsenal of guidelines, proformas, protocols and checklists. We try to manage complexity by funnelling patients down specific pathways; often through a series of literal check-boxes or flow-charts. By asking a few key questions or following a set pathway a doctor can help minimise the risk of catastrophic errors and reassure the patient (and themselves) that they’re receiving the most appropriate care.
Much of this approach has been borrowed from the airline industry, which is held up by some as the epitome of a safety-conscious industry with its emphasis on checks, counter-checks, and clearly defined responses to any possible event. This thinking has lead to the introduction of innovations such as the World Health Organisation’s surgical checklist, a beautifully simple tool that has reduced surgical mortality by up to 50% simply by making sure a few basic tasks were completed; such as the correct identification of the patient, the proper preparation of all the equipment and the proper identification of all team members (5). In an era of cardiac magnetic resonance imaging and immune-modulating cancer drugs these precautions sound laughably simple, but the fact that the checklist took so long to be invented shows how patient safety innovations have long lagged behind exciting and expensive diagnostics or therapeutics.
Much of the evidence supporting checklists comes from surgery or intensive care, highly controlled environments in which patients are usually heavily sedated (6). But most medical interactions aren’t like a sterile operating theatre or a cool intensive care department, doctor-patient consultations are inherently complex and vague; taking a history from a worried patient in a busy emergency department is fundamentally different from reviewing medical equipment before open-heart surgery. Yet we have tried to export many of the same tools and principles as our best defence against our own mistakes in the hope that something must be better than nothing; but despite the importance of the subject we have much less evidence to support our patient safety initiatives than any other intervention in medicine.
Not only might checklists not work, but they might be encouraging the wrong sort of medicine. By seeing a patient as a series of check-box questions or a pathway to navigate, we risk losing sight of that person as a whole individual in a wider context. As patients become more complicated with a wider variety of simultaneous ailments, the efforts to shoe-horn medical decision making into rigid pathways or silos will make empathic, holistic care more and more difficult.
Instead of blindly expanding checklists and proformas which may not work and which may alienate doctors from their patients, we should be looking at patient-safety tools that support the sort of holistic care that doctors and nurses want to provide. New techniques in artificial intelligence and natural language processing offer an opportunity to design tools that are more applicable to the nuanced world of modern medical practice and allow clinicians to practice safer medicine than ever before. For example, instead of the current stream of tick-boxes and pop-ups, we could design technology that reads free-form medical documentation and alerts doctors and nurses to potential mistakes before they ever take place.
Patient safety has been neglected by medicine, it took us 300 years to develop a simple surgical checklist and we cannot wait another 300 years for the next leap forward considering the daily impact of avoidable mistakes on patients and their doctors. The new wave of technology offers us an opportunity to not only improve the safety of our care but also to re-position compassion and human connections at the centre of modern medical care.
- Forbes. The True Cost Of Medical Malpractice — It May Surprise You. 2010. https://www.forbes.com/sites/rickungar/2010/09/07/the-true-cost-of-medical-malpractice-it-may-surprise-you/
- BMJ. Clinical Negligence: NHS paid out £2.4bn last year. BMJ 2019. https://www.bmj.com/content/366/bmj.l4688
- Guardian UK. NHS compensation payouts ‘unsustainable’, say health leaders. 2018 https://www.theguardian.com/society/2018/feb/02/nhs-compensation-payouts-unsustainable-say-health-leaders
- World Health Organisation. 10 facts on patient safety. WHO 2019. https://www.who.int/features/factfiles/patient_safety/en/#targetText=Globally%2C%20as%20many%20as%20four,and%20the%20use%20of%20medicines.
- Heinz AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009; 360:491–499
- Ko HC, Turner TJ, Finnigan MA. Systematic review of safety checklists for use by medical care teams in acute hospital settings — limited evidence of effectiveness. BMC Health Serv Res 2011; 11:211.