DR. MIRIAM SHUCHMAN

Tuesday, September 7, 1999

Ten-year-old Lisa Shore was in severe pain from a chronic leg condition one evening last October. Her parents took her to the Hospital for Sick Children, where a doctor gave her morphine to relieve the pain, and admitted her overnight. The next morning she was dead.

Lisa had a chronic pain problem, not a fatal disease. Her mother has struggled with why she died. She's convinced her daughter was a victim of medical error. Sharon Shore alleges that a doctor in the emergency room had written orders for Lisa to be closely monitored, but the orders were in the computer, where they went unseen by nurses taking care of Lisa. A coroner's inquest is scheduled for this fall. (Sick Kids cannot comment, according to a hospital spokesperson.)

If the coroner finds that Lisa died as a result of a mistake, will the inquest prevent similar mistakes in the future? That's unclear. Coroners' inquests are intended to prevent future deaths, but there's no data showing that they have that desired effect.

Dr. Barry McLellan, a regional coroner in Ontario, defends the inquest process. ''Part of error management is learning from errors which have occurred,'' he points out. ''With an inquest, the recommendations are widely disseminated across the whole province so institutions can benefit from understanding what went wrong and make changes in their own institution.''

After a child died at Peel Memorial Hospital last year, an inquest jury recommended that computer documentation systems be streamlined. Peel Memorial has since taken steps to ensure that all orders and notes about patients are recorded in a single patient record. That's the sort of recommendation and response that experts in medical errors, such as Harvard's Dr. Lucian Leape, would applaud. Dr. Leape believes hospitals should redesign and reorganize their systems so as to minimize the chance for errors. But it's not clear that other Ontario hospitals took actions based on the inquest jury's recommendations to Peel Memorial, even though the recommendations went to every hospital. And Sharon Shore believes one of the reasons her daughter died was that the doctor's orders were in the electronic but not the written record.

For her part, Ms. Shore is hopeful that publicity about the inquest will make a difference. ''The public awareness puts a lot of pressure on the hospital to make the changes and to prove to people that they made the changes,'' she says.

Just as coroners offer feedback to institutions, physicians' regulatory bodies are providing feedback to individual doctors. Last year in Alberta, the College of Physicians and Surgeons received 770 complaints. In an effort to reduce that figure, the College launched a program this past February in which each of Alberta's 4,700 physicians will be assessed by their peers and their patients, once every five years. The program aims to help doctors improve the quality of their practice. The College also wants doctors to do a better job of communicating with patients, since more than half of last year's complaints related to issues of doctor-patient communication.

Assessing doctors seems worth a try. A 1998 Ontario study on physician assessment found that doctors subjected to a review by other doctors improved, at least in the short term, say, over the next five to six years. Partly as a result of these findings, Ontario is seriously considering mandatory performance reviews for every one of its 20,000 physicians.

Getting doctors to change the way they've always done things is without question, an uphill battle. As Dr. Roy Poses of Rhode Island's Brown University explained in a recent article, ''Physician's behavior appears to be resistant to change. Many well-intentioned interventions have failed to change their behavior.''

Canadian doctors who reviewed over one hundred programs aimed at improving doctors' practice in the Canadian Medical Association Journal in 1995, titled their article, No magic bullets. Those who study hospitals might be just as sanguine about the ability of medical institutions to change in substantial ways.

Most treatment-related injuries that patients suffer while in hospital ''are due to errors and are therefore, potentially preventable,'' according to Dr. Leape. The trick lies in figuring out how to prevent them. Regulatory bodies may be able to help doctors and nurses perform better, but this is only part of the answer. Medical errors aren't always due to an individual's incompetence. Problems in hospital systems often contribute. Hospital leaders have to be creative in thinking about errors and open to change.

In closing, a word of caution. Though the error rate is high in medicine, the odds still strongly favour going to the hospital when you need treatment. In the best study of errors to date, 96 per cent of patients hospitalized in New York state went home after treatment without ever having experienced an error-related injury. 
 

E-mail Dr. Shuchman at:
shuchman@acsu.buffalo.edu