UCSF physicians publish groundbreaking book on medical mistakes; author to speak at public event on

By Maureen McInaney

Nearly five years after an Institute of Medicine report put medical mistakes on the public’s radar screen, two UCSF Medical Center physicians have published a groundbreaking discussion of why errors occur and what health care providers and leaders must do to cure this epidemic.

The book, Internal Bleeding: The Truth Behind America’s Terrifying Epidemic of Medical Mistakes, was published today by Rugged Land Publishers, New York.

One of the authors, Robert M. Wachter, MD, chief of the medical service and chair of the patient safety committee at UCSF Medical Center, will discuss the topic at a public forum on the UCSF campus as part of the UCSF Osher Lifelong Learning Institute.  The event, which features Wachter in conversation with KQED’s Michael Krasny, will take place Wednesday, February 25 at 7 PM.  Tickets are $15. More information is available at http://lifelonglearning.ucsf.edu.

Wachter, also a UCSF professor of medicine, and co-author Kaveh G. Shojania, MD, UCSF assistant professor of medicine, have pioneered a case-based approach to teaching doctors, nurses, administrators and patients about medical mistakes.

Their case-based approach first appeared in a series in the Annals of Internal Medicine called “Quality Grand Rounds,” and later in their federally-sponsored web-based medical errors journal, AHRQ WebM&M (http://webmm.ahrq.gov).

“In Internal Bleeding, we extend our approach of pulling back the curtain to discuss dramatic and compelling stories of medical mistakes, accompanied by evidence-based insights and research that points the way toward solutions,” said Wachter.

He explained that the book describes previously reported and well-known cases from clinics and hospitals around the country, such as a case in which a neurosurgeon operated on the wrong side of two different patients’ brains and a case in which a Canadian woman had a crowbar-sized surgical instrument left in her abdomen.

Internal Bleeding also includes a dozen other cases gathered from around the country and presented anonymously. They include the patient who received another patient’s heart surgery because of a name mix-up, the ICU patient who had a seizure and died when an intravenous line was inadvertently flushed with a dose of insulin rather than a blood thinner, and the heart attack patient mistakenly and fatally discharged from the emergency room.

“Through these cases, we argue that faulty systems, rather than bad people, are responsible for most medical errors, and that fixing this epidemic will take new resources, approaches, culture, and training,” said Wachter.

“The cases are less horror stories of malfeasance or incompetence than cautionary tales about misguided priorities, mixed signals, and mass denial. They range from congressional decisions about what kinds of research to fund, to choices by hospitals about where to focus their attention and dollars, to judgments by medical and nursing schools about how to train the healers of tomorrow.”

Wachter and Shojania provide detailed recommendations about what physicians, nurses, hospital CEOs, regulators and policymakers can do. Among the suggestions:  1) create systems to prevent “handoff” errors when patients or information are transferred from one place to another, 2) implement computerized solutions to prevent medication errors, and 3) transform the culture of hospitals, using models drawn from the aviation industry, to emphasize teamwork and create opportunities for learning after errors and near-misses.

The authors also include a checklist of questions that patients should ask their hospital, doctor, or health plan to be sure their providers are focusing on patient safety (available at www.ruggedland.com/internalbleeding).

“I am pleased that two of our faculty physicians who lead our patient safety initiatives at UCSF Medical Center have taken lessons learned from hospitals around the country to provide an analysis of why and how medical errors occur,” said Mark Laret, CEO of UCSF Medical Center, which has been ranked by US News & World Report as one of America’s top ten hospitals.

“I believe Drs. Wachter and Shojania have identified the major issues we must address in order to make our nation’s healthcare system not only the most technically advanced in the world, but the safest.”

Harvard’s Atul Gawande, MD, author of Complications: A Surgeon’s Notes on an Imperfect Science, said “Internal Bleeding is utterly compelling.  Dramatic and unflinching, it gives us both the stories of what really happens when things go wrong in medicine and the research that explains what needs to be done.”

David Kessler, MD, dean of the UCSF School of Medicine and former FDA commissioner said, “Internal Bleeding is ER meets Fast Food Nation.  By pulling back the curtain to show us the hidden world of doctors and nurses, it paints a remarkable and unforgettable picture of how medical mistakes happen, and what must be done to cure this modern epidemic. It is a fascinating and essential read for both patients and medical professionals.”

Wachter is a national leader of the “hospitalist” movement, the fastest growing medical specialty in the United States.  Hospitalists are physicians who focus on the care of hospitalized patients, and on improving hospital systems of care.  Wachter coined the term “hospitalist” in the New England Journal of Medicine, was the first elected president of the Society of Hospital Medicine, and directs UCSF’s 17-member hospitalist group.  Shojania, also a hospitalist patient safety researcher, edited a major federal report on evidence-based patient safety practices and won the 2002 Young Investigator Award of the Society of Hospital Medicine.