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Chat Transcript: Dr. Gordon Schiff on medical mistakes

(CNN) -- Dr. Gordon Schiff discussed the medical errors estimated to produce more than 44,000 deaths in the United States each year during a chat on December 7, 1999. Dr. Schiff serves as Director of Clinical Quality Research in the Collaborative Research Unit of the Department of Medicine at Cook County Hospital in Chicago.

He chairs the hospital's Drug Usage Evaluation Committee. And for the past decade, Dr. Schiff has been the medical director of CCH's general-medicine outpatient clinic and co-chair of the hospital's quality assurance and improvement committee. The following is an edited transcript of the chat.
Medical errors

Chat Moderator: Welcome Dr. Schiff.

Dr. Schiff: Hello, I'm glad to be here.

Question from Candyce: What kinds of medical mistakes are we seeing that require this task force action?

Dr. Schiff: There has been a wide spectrum of problems that have been uncovered since we have been shining a spotlight on these problems. Medication errors have receive a good deal of attention -- wrong drug, wrong dose, and medications that interact with other medications a patient is taking.

Question from phish: What are the consequences for this problem in terms of those who are getting medical treatments. How are we affected and how can we respond?

Dr. Schiff: First of all, I don't think the recent publicity should induce a sense of panic, or even immediate worry for patients receiving care. These problems have always been there; we are just shining a spotlight on them đ with the hope of preventing them. Being a well-informed and questioning patient is one key strategy. Don't take for granted that a busy physician or pharmacist will have double checked everything. You can play a big role. Anything that doesn't sound right should be questioned. A final role for the public is to insist that the professions work toward systematic solutions to these problems. This includes new, more meaningful ways to stimulate reporting and investigating these problems, and putting tools in place (such as computerized drug ordering) that can intercept errors before they reach the patient.

Question from Dave: If these problems have always been there, why haven't physicians practiced "process improvement?"

Dr. Schiff: There have been less coordinated and less visible efforts going on for many years. The "morbidity and mortality" conferences that take place in most every hospital are an example. However creating a culture and a method to get to the root of the problems in a systematic way is happening now due to a number of healthy developments, including increased public demands and media attention.

Question from Faith: As a nurse, I feel that the staff to patient ratio has a great deal to do with errors. Does your research so far address this issue?

Dr. Schiff: There is some evidence that staffing ratios and stresses on the pace of work do contribute to errors, and I personally share your concerns here. The work of a number of nurse/researchers, which has been reported by medical writer Suzanne Gordon, has discussed this in greater detail.

Question from Dave: No one wants to, or should, point fingers, but haven't most of the solutions brought forth to date focused on hospital-led efforts? Where are the physician organizations?

Dr. Schiff: I would say that all sectors have been too slow in moving forward on this front. Ironically, and somewhat counter to your assumption, I'd say that the AMA has actually been in the lead for some of these efforts. They sponsored the Annenberg Error in Medicine Conference, with reports available on Web. And the AMA has a National Patient Safety Foundation. I say this not as any fan of the AMA, especially since they blocked national health insurance.

Question from Philo: Why are physicians so busy? Are you making any recommendations to remove the restrictions on medical education to produce physicians who have the time to check for mistakes?

Dr. Schiff: This question requires a one hour discussion and answer; but I guess we don't have the time to do it justice. I'd start by looking at the demands on doctors for faster throughput by managed care firms, who are increasingly scheduling and expecting doctors to see five, six or more patients per hour. Next, I think it must be said that doctors' time is also distracted by many demands for paperwork, administrative insurance work, that takes away from time with the patient. But having said this, the solution is much bigger than the doctor. And I'm not saying the doctor is not part of the problem or solution. But if we want to make significant progress, we're going to have to think about "re-engineering" a lot of how we practice, and get feedback on what we do. We're also going to have to use the talents of everyone in the health care team to play a role, including pharmacists to check and counsel patients.

Question from GUS: Is this problem statistically different in other countries? How do we compare?

Dr. Schiff: To my knowledge there are no cross-national comparisons. There is every reason to expect that these are generic problem and are similar elsewhere. Some doctors in the U.S. have been pioneers in this field, for example Don Berwick, Lucian Leape, David Bates, and Michael Cohen of PharmD, so this is in part why the spotlight has been on U.S. studies.

Question from Dave: Dr. Schiff, is part of the problem that most physicians practice as individuals or small groups, and as such when they "make a mistake" that one issue can threaten their whole livelihood?

Dr. Schiff: We have not gotten into the issues related to fear of learning and uncovering mistakes, but need to. If each practitioner has to individually commit each error and learn from his or her own mistakes, we have a very inefficient and dangerous learning system. What we need are ways to share, report, collate, and investigate problems, such as is done in the airline industry. The aim needs to be to fix problems not fix blame.

Question from thinkboutit: Does today's litigation-happy climate hold down efforts to analyze and report errors?

Dr. Schiff: You have hit on a critical point. Fear of malpractice lawsuits does tend to promote a climate of hiding and denying problems, not seeking them out and sharing them. How to get around this has been the subject of much discussion, especially if you believe, as I do, not that patients are litigation happy, but that they have the right to have genuine malpractice (which is not uncommon) accounted for, redressed, and compensated. Often, families sue just to seek satisfaction that what happened to them or their relatives, will not happen to others. This is a noble, not a litigation happy impulse.

Question from Go-seki: How much do you think fatigue can be blamed for many of these misadventures?

Question from MikeC: The recently released report on medical errors made no mention of the ridiculously long shifts that residents work. Do you think that reducing shift length would have a positive effect on errors?

Dr. Schiff: Human factors such as stress, fatigue, and distractions are unquestionably significant contributors to errors. We are learning more about the impact of such factors from work outside of medicine. Again, people like Lucian Leape of Harvard School of Public Health have helped us understand. The public needs to be vigilant to see that patient safety is put ahead of the bottom line, something that can no longer be taken for granted. I urge anyone interested in learning more about these issues to e-mail me with their address and I can send them some of my work as well as some of the references I've cited above. My e-mail address is One of the things I've been most interesting in is computerized prescribing so that the days of illegible handwritten prescriptions come to an end. Software has been lagging behind in this area, but there are many emerging products and web-based solutions. These need more attention, and I urge anyone with an interest in this to get in touch with me. Finally, we need to work together to get at the root of errors, learn as much as we can each time one happens, or a near miss occurs. In this way, all of the sensational publicity can be effectively channeled into real change. The problem has always been there and is not going to go away when the headlines recede. The public needs to demand this sort of accountability and I am hopeful that the current attention will be one step in this direction.

Chat Moderator: Thank you Dr. Schiff for joining us today.

Dr. Schiff: Thanks for letting me experience this new medium--and brush up on my typing skills, which I hope to be using to prescribe medicines in the near future!

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New York clears way for electronic medication transactions
May 7, 1999

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