Most of us are not aware of the alarming in-patient mortality rate from medical errors. Ten to 20 percent of people undergoing an inpatient or outpatient surgical procedure are apt to get an infection in the United States.
More than 30 percent of hospital deaths in the hospital arise from people picking up an infection in the hospital.
Yes, you read that correctly.
If these statistics were about skiers dying as a consequence of the sport, most of us reading this article would quickly demand thorough investigations. Many people or their family members in Vermont are hospitalized, yet we are largely unaware of the magnitude of this problem.
Accurate statistics on medical errors, especially infections from hospitalizations, are difficult to find and in fact are often not recorded by clinicians in hospitals. The statistics most often cited are from reports from the Institute of Medicine and Center of Disease Control which compare admission and discharge diagnoses.
The lack of accurate data has not stopped forward-looking entrepreneurs from investing millions of dollars in “solutions,” such as computerized cleaning robots, novel bacteria-killing surface materials and hand washing monitors.
How will we know which strategies are truly beneficial if we don’t have a baseline to compare to?
Why are hospitals reluctant to gather this data, without which interventions are impossible to monitor and analyze for beneficial results? Why are physicians and other healthcare staff members afraid to admit to, much less document, a medication mistake or breach of protocol?
In addition to patient deaths, what toll does the hiding of these problems take on hospital staff?
There are powerful motivations for secrecy. Open disclosure could be financially debilitating for hospitals and individual clinicians due to penalties imposed by the U.S. government Center for Medicare and Medicaid and by expensive malpractice suits.
The Toyota automobile production system, an often-referred to quality control model, asks five “whys” whenever a defect in manufacturing is discovered. By the fifth “why” the answer always lies in individual human actions. With the fifth “why” in mind, I choose to ask why clinical providers whose training and work is to take care of patients feel that it is a safer and better choice to keep mistakes to themselves.
The problem lies in part with physicians, of which I am one.
What generalities can be made about our personality traits?
Physicians strive for independence and control — great qualities when managing a medical emergency. We are selected by medical schools for our ability to be leaders, not team members. When we make a mistake, do these same traits make it easy to for us to confide in our colleagues or administrative staff? Too often the answer is “no.”
Yes, there are powerful incentives not to tell: fear of looking stupid, loss of our sense of competence, loss of job and income, malpractice suits and increased insurance rates.
And yet, when we don’t tell, we violate our goals to be healers. Secrets beget secrets. They isolate us from our colleagues, keep us awake at night and can kill our patients.
What tools are available to these physicians?
Patients are the priority in hospitals, and when patients begin to demand answers and explanations on hygiene protocols, hospitals and physicians will respond.
And if we are honest about this problem we will respond with something like a 12-step program to go from darkness to light in the fight to tighten the noose on hospital-born infections.
It goes like this:
Infections anonymous, a new 12-step program with the following pledge.
“The process of working the steps is intended to grow a moral consciousness and willingness for self-sacrifice and unselfish constructive action.”
Step 1: Honestly admit we are powerless against causing infections in our patients as we now practice. In other words, change is imperative.
Step 2: Develop the understanding that we are not alone, that together we can fight this battle.
Step 3: Surrender the idea that we can solve our problem alone. The solution is a process, not an event. As we work together more will surely be revealed.
Step 4: Make a searching and fearless moral inventory of ourselves.
Step 5: Admit to ourselves and to another human being (not the hospital lawyer) the exact nature of our wrongs.
Step 6: Be entirely ready to receive help in correcting our behaviors.
Step 7: With a new sense of humility, ask for help to do something that cannot be done alone by self-will or mere determination.
Step 8: Make a list of all persons we have harmed, and became willing to make amends to them all.
Step 9: Make direct amends to such people wherever possible, except when to do so would injure them or others.
Step 10: Continue to take personal inventory, and when we are wrong, promptly admit it.
Step 11: Seek to improve our conscious contact with a larger group.
Step 12: Achieving a lower infection rate as the result of these steps, we will try to carry this message to other physicians, and to practice these principles in all our clinical affairs.
My thoughts are not an exact recipe for a new noon hospital meeting. The 12-steps, however, have helped people with a myriad of destructive and isolating behaviors.
They are a time-tested process, which could be adapted to help clinical providers unite to understand the many factors leading to infections and other errors in hospitals. Clinicians’ psychological wellbeing would improve, infection control departments could gather accurate baseline data to evaluate safety interventions — and most importantly fewer patients would die as a result of being in the hospital.