That was a headline in an E-mail that I received today from Michelle, and the premise of the content of that E-mail was that one cause of the medical errors which contribute to a significant number of deaths in America’s hospital is the continuous use or overuse of safety alerts in Information Technology programs. Their hypothesis was that these alert are programmed to happen so often that the healthcare professionals begin to ignore them altogether and thus miss the significant ones. They referred to this as ALERT FATIGUE. Interesting premise and there most probably is some truth to this.
Michelle’s E-mail was promoting Wolters Kluwer Clinical Drug Information’s (CDI) Technology, and they wanted me to call them to write a blog about their technology. Obviously, I didn’t, but they did get a free plug here so that I’d have some reason to start this entry with that attention-getting headline. I’m sure alert fatigue plays some part in some medical errors.
But the number one cause of medical errors that can lead to death is humanness. One of my scientists would become infuriated if someone compared going to the moon to curing cancer because, according to him, the moon shot was primarily controlled through engineering and cancer cures require deep science. Of course, he was referring only to those portions of the trip that were not science related which were, hmmm? None? It was the combination of science and engineering that made it work, but the humans sure as heck played a major part in its success. Just like in healthcare, the medical errors can come from science and engineering, but most of all, those errors come from humans.
In my book, “Taking the Hell Out of Healthcare,”I stressed patient advocacy. At the tender age of 13, I observed my grandfather die needlessly because there was construction dust in an operating room that kept him unnecessarily bedridden for a week. The inactivity resulted in a DVT (deep vein thrombosis) that killed him. From that day forward, it was clear to me that the patient better have an advocate for as many hours a day as possible because it could save their life. More importantly, it had better be someone who knows a little something about healthcare because it only takes one mistake to begin a cascade of unhappiness.
I’ve always believed there is a potential profession in patient advocacy. Physician Assistants or Nurse Practitioners could work to ensure the patient is treated, medicated, and nurtured appropriately, and they would make a small fortune from those who could afford them.
What about the rest of us? Just having someone who cares a little bit about your well-being standing nearby to ask prudent person questions when you’re sleeping, confused, or befuddled by the medical speak that’s going on around you could save your life.
I’m not a doctor, not a scientist, and surely not a genius, but I do know that humanness is what leads to errors which lead to death. Those errors are human errors. They may be because someone didn’t learn about something in school or because they forgot, or they were tired, or sleepy, or angry, or fearful, but they do happen, and if someone simply says, “What’s that pill for, and why does my friend need that pill?” It could lead to appropriate answers.
I’ve seen hundreds, no thousands of documents detailing medical errors that could have resulted in liabilities for the hospitals where I worked, and those documents always told the story of how one professional forgot to communicate something to the next professional or how someone misunderstood a written order or they didn’t check a wristband, and the story goes on and on.
Get someone. Pay someone if you must in order to stand by you. The wonderful people who work in hospitals are there because they care, but long hours, traumatic situations, labor pressures, and more contribute to accidents. Make sure you’re not one of them.