Is zero possible?

Can the goal of zero errors ever be achieved in the medical field? High risk but complex industries such as aviation and nuclear power set a precedent of admirable safety records, that approach that zero mark.

But is this an attainable goal in medicine? To me, certain aspects of this goal feel manageable, while other feel as though they could be insurmountable. With technology as an adjunct, medication errors are reduced via the use of bar code and electronic versus hand written orders. EMRs can also be designed to prompt reminders if a dose is well beyond the typical limits or the drug interacts with another of the patient’s medications. Similarly, the path to reducing complications from typical procedures also seems clear. Standardized bundles of supplies, clear protocols for the procedure, increased adherence to maintenance of a sterile field all contribute to decreased risk for the patient.

Eliminating medical error in the form of misdiagnosis seems much more daunting than reducing errors from a specific procedure. While one represents the product or an external system, the other represents the outcome of an internally designed system. The diagnosis represents the product of a combination of education, perception, communication and physical findings. Sometimes even a thoughtful and appropriate diagnosis is incorrect, as the provider is faced with a rare or atypical presentation of disease.

While skepticism is merited, pessimism should also be curtailed. Years ago it was thought that it was impossible for a major institution to go days, weeks or months without a central line infection. Yet now, proper protocols and procedures allow some institutions to go months to years without an infection. Perhaps a similar trajectory will be achieved for diagnostic errors.

After reflecting on this paradigm, my take away is not the diagnostic errors must be eliminated all together, but that providers must avoid errors in thought processes such as premature closure or anchoring. We will never live in a world where the initial diagnosis is correct 100% of the time. But we can create a culture of a constant revision and reevaluation of diagnostic conclusions, in which new data – in the form of vitals, patient’s symptoms and physical exam – are incorporated into a constant reassessment of conclusions. While the initial assessment may not always lead to the correct diagnosis, an attitude of reevaluation and a high index of suspicion can lead to the correct diagnosis more quickly and reduce the harm to patients.

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