Medical Error: What Do We Know? What Do We Do?. Eds Marilynn M Rosenthal, Kathleen M Sutcliffe. Jossey-Bass, $45, pp 368. ISBN 0 7879 6395 X. For ordering details, see www.josseybass.com. Rating: ★★★
The causes of medical error are well documented: stress, burnout, and loss of autonomy among physicians; nurses' unwillingness to challenge or question doctors' actions; the complexity and interdependence of medical procedures; fear of litigation; and strained resources. More than 80% of medical error, though, according to this book, can be blamed on non-communication or miscommunication. And what we do about all this is, like medicine itself, not entirely an exact science.
This book emerged from a conference at the University of Michigan, where its editors are professors. Their purpose is to present views on the subject of medical error “articulated by the best people we can find.” On the whole, they deliver on that promise, although there's inevitably some repetition and not a little “academespeak.”
Among the proposals are a non-punitive climate for error reporting; a 14-point strategy for medication errors; improved communication between doctors and patients; a stronger focus on evidence based medicine, best practices, and standardisation of procedures; an emphasis on risk management and particularly its teaching in medical schools; swifter and wider adoption of information technology; and greatly expanded research.
In all of this, some contributors point out, doctors must lead and dominate patient safety initiatives. Primary care, they note, is a particularly fertile area for research and action, and one that is hardly addressed in the 1999 Institute of Medicine report, which claimed that 98 000 US deaths a year could be attributed to medical error. As a result of shorter hospital stays and a consequent increase in the acute care provided in outpatient settings, the authors say, the office practice setting could yield a greater margin for improvement.
It's in the controversial area of applying systems solutions to patient safety—particularly those in the aviation industry—that this book is especially helpful. But the word system, according to one contributor, “carries the notion of an entity that is mechanical, orderly, designed, impervious to improvisation, stable, and routinized.” All of that may be true for aircraft, where accidents are infrequent, highly visible, and often involve massive loss of life, which, in contrast to medicine, may even include the lives of the professionals themselves. Moreover, patients are more complex than aeroplanes, and a cockpit crew is a clearly defined team with a formal hierarchy of authority that makes decisions during a flight, which has a clear beginning and end. Medicine, by contrast, is open ended and involves many more people. However, it is beginning to adopt aviation's approach by using incident reports, survey data, and direct observation—and especially by paying more attention to normal operations—a data source the authors say is vastly underused in healthcare.
The editors helpfully append 16 pages of definitions—some of which, such as negligence, mistakes, and incident, may seem pretty obvious—and a collection of website information. Overall, this is a timely and useful review of a topic that has assumed major importance in health care.