The Cost of Human Error

In September 2010, a seasoned pediatric intensive care unit nurse administered an accidental overdose to a critically ill baby, giving ten times the amount of calcium that was prescribed. Five days later, this baby, with an already tenuous heart condition, died. The nurse recognized her mistake immediately, informed her superior, and also told the family and physicians. She was, however, escorted out of the hospital, put on administrative leave, and fired soon thereafter. In April 2011, she took her own life.

The nurse clearly made a mistake; an avoidable one at that, and it may have contributed to this baby’s demise. We are all human, and we all make mistakes. But in medicine, these mistakes can cost a life. Such ‘mistakes’ occur almost 200,000 times annually in hospitals throughout this country. These disastrous mistakes are oftentimes person-induced medical errors, either from carelessness, lack of adequate knowledge, or, in this case, inattention to overly rote procedures that seemingly do not require a seasoned health professional’s complete focus. Some events occur as a result of systems errors. While computer programs in hospitals now offer ‘alerts’ to minimize dosing or treatment errors, such errors still occur.

As part of the continuing effort to eliminate mistakes in the operating room, many now routinely perform ‘time-outs’ before each surgery, whereby the entire staff in the room confirms patient identification, medical allergies, site of surgery, equipment needed, anticipated events, and personnel present. The operating surgeon then states that anyone should voice their concern at any time, should there be an unnoticed event or potential error. It is literally a ‘time-out’ where everyone stops what they’re doing, and listens. At the end of each surgery, all personnel participate in a ‘debriefing’ , where they review whether or not all went as planned, and, if not, what measures were carried out to handle any changes. While many experienced surgeons and nurses balked at these ‘time outs’ and ‘debriefings’, surgical errors have indeed been reduced, and even the most skeptical have incorporated and welcomed these moments, in efforts to minimize error.

But even when all goes perfectly in medicine or surgery, bad things can happen in a medical environment. Many of us treat critically ill patients, on the verge of death. Some will die no matter how heroic our efforts. Some die in our hands– literally. Most medical institutions have built-in counseling and support systems in place to help a grieving family– emotionally, spiritually, and even logistically. This is a good thing. But medical personnel are also human, and for us there is little or no built-in support system in hospitals for those closely involved in the death of a patient, be it from error or not. As a medical or surgical team, we have each other. And we have our families and friends. But while the institutional support for grieving families is a well-oiled machine, there is no such machine to mop up the tears of the staff. While robotic surgery has become the rage, we as physicians, nurses, staff, and students, are not robots, and we could use a post-mortem, supportive ‘debriefing’ in the hope of healing our wounds and hopefully continuing to heal those of others. Maybe, with these support systems, we can save the next nurse (or doctor) who errs.