Embrace technology to stop prescription mistakes

Commentary. By Eric Anderson, MD, AMNews contributor. Jan. 27, 2003.

COMMENTARY

Observations on the state of medical practice and medical life

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When we were medical students we were innocent, wide-eyed, hesitant, so we didn't make mistakes. As interns we were indefatigable, immortal, alphas rampant, so we never made mistakes. As young doctors we were thoughtful, skilled, very well-trained, so we couldn't make mistakes. As senior physicians we were confident, knowledgeable and too experienced to make mistakes.

Yet, we made them.

I thought about this at a hospital staff meeting in the 1970s when an earnest young urologist reported an incident in another hospital where he ran the quality assurance program. A physician had just delivered a baby and as he walked with it to the bassinet he slipped on a floor slick with amniotic fluid -- and dropped the baby on its head! The baby was brain damaged.

That surely subdued a room full of doctors hearing this story. The immediate reaction in our hospital was to decide that a physician who had just delivered a baby would stand still, hand the baby over the mother's abdomen to a nurse on a dry floor who would then walk with the baby over to the bassinet.

This protocol wouldn't help the infant in the other hospital but it would protect other babies from similar catastrophes. Once we recognized the problem we took steps to deal with it. And that's logical.

The problem is we don't hear enough about errors and, when we do, we tend not to believe them. I have trouble, myself, accepting some of the extrapolated figures from the oft-quoted studies. It seems preposterous that medical mistakes could account for 44,000 to 98,000 deaths per year in the United States, or that the cost of medical errors lies between $17 billion and $29 billion a year.