Seeing error through new lenses.

Medical error emerged as a matter of public policy with the November 1999 release of an Institute of Medicine (IOM) report entitled To Err is Human.1 With the exception of about-to-be-released data on adverse events in Colorado and Utah hospitals,2 the report presented little new information and, in fact, echoed many of the themes laid out a year earlier in the report of the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry.3 Nevertheless, the IOM report attracted national media attention and led to a cascade of events that included the creation of a federal interagency task force and a multimillion dollar commitment by the Agency for Healthcare Research and Quality to patient safety research.4,5 In addition, the report prompted organizations such as the American Hospital Association, the Joint Commission on Accreditation of Healthcare Organizations, the National Quality Form, and the Leapfrog Group to accelerate their efforts in this area. Medical error and its less pejorative twin, patient safety, were transformed overnight from a health services research backwater of particular concern to risk managers, health care critics, and soulful practitioners into an area of widespread interest.6–9 The transformation illustrated rather dramatically the invention of a social problem.10 With IOM as midwife, our society collectively redefined medical error from the awkward issue of physicians' professional (in)competence into the promising application of industrial safety techniques to health care organizations. The IOM report amplified Leape's observation that medical error was prevalent and potentially preventable, and could be understood as the product of poorly designed systems of care rather than defective individuals.11,12 The patient safety example challenges us to consider whether other aspects of our professional and personal experiences harbor serious, perhaps unrecognized social problems. As 1937 Nobel laureate in medicine Albert von Szent-Gyorgyi quipped, “Discovery consists of seeing what everybody has seen and thinking what nobody has thought.”13 The daily pace of work undermines our ability to recognize problematic phenomena in everyday experience. We quickly numb to the impossible and ridiculous in our practice, teaching, research, and management responsibilities. Perhaps we become desensitized as trainees to the SNAFUs that characterize modern medicine, regarding errors and accidents as normal and expected events in the care of patients. Several articles in this month's Journal illustrate the authors' capacity to recognize medical error in everyday experience. Chaudhry and colleagues showed that attending hospitalists, in the course of routine clinical care, could identify near-miss errors in 6.2% of admissions and adverse events in 4.2%.14 Similarly, Moore and colleagues looked with fresh eyes at the outpatient medical records of patients recently discharged from their academic medical center for errors related to medications, test follow-up, and failure to completed proposed work-ups.15 Forty-nine percent of patients experienced at least 1 error, and work-up errors (most commonly, failure to complete a work-up for gastrointestinal or vaginal bleeding) were associated with a 6-fold increased risk of readmission. New lenses also help us to see solutions to patient safety problems. Chaudhry et al., in demonstrating a role for hospitalist physicians in early detection of adverse events, identify in the hospitalist community an important constituency for safety and an instrument of improvement. Moore et al. spotlight the importance of transitions in care, particularly from inpatient to ambulatory settings. Their work echoes another recent study that identified preventable or treatable adverse events among 12% of newly discharged patients.16 Together, these studies of transitions challenge the adequacy of “usual care” and suggest opportunities for improvement. For example, what robust mechanisms can be developed to ensure that discharge recommendations are forwarded to the appropriate clinician? Should inpatient physicians be responsible for posthospital follow up? Should patients receive copies of their medical records at the time of discharge? Or should personal health records become the norm? Similarly, Orlander and Fincke showed that the Morbidity and Mortality Conference is alive and well in 90% of the U.S. internal medicine training programs whose leaders responded to their survey.17 They found significant variation, however, in the content and format of the conference. The authors suggested that programs use the M&M Conference in a more deliberate way to report on and learn from cases of medical error.18 New lenses reveal new problems as well as new solutions. The willingness of generalist physicians to take a fresh look at the way that medical error is embedded in common experience and everyday practice is a tribute to the vitality of the profession. Indeed, generalist physicians are particularly well positioned to lead the development of patient safety innovations in education, research, and clinical care. I am cautiously optimistic about our collective ability to embrace the revolutionary idea that error is a key to excellence, and to embody this concept in all facets of our work.