The good news here, however, is that by simply launching a study of this nature and capturing the data it is reasonable to expect that any hospitalist group could take it on and any hospital’s quality of care would be improved.
“There is a spectrum of practice review that is conducted by a variety of people,” says Dr. Chaudhry. “On one end of the spectrum, you have the uninvolved reviewer coming in and doing formal chart reviews … and our process was at other end of spectrum, where we were going about our daily business, the routine clinical care of patients.”
By maintaining the potential for errors at the forefront of their thinking, she says, it became the background against which they performed the constant daily review of patient data. “When I would go to the bedside in the morning,” she says, “to see the patient, talk to the patient, review the chart, look at notes, look at vitals, look at meds—that was my process for picking up on errors.”
—Saul Weingart, MD, PhD
Barriers and Opportunities
There are two major barriers to performing this kind of research in other institutions where hospitalists practice, but they are easily resolved. The first is the importance of standardizing definitions.
“We came to consensus before the study began of what things should count and what things shouldn’t count,” says Dr. Chaudhry. “Because there is a degree of subjectivity and especially when a patient experiences harm, it’s a bit easier to attribute that to an error—though not always. For instance, with a patient with asthma who ends up with fluid overload and gets intubated. Well, was that an error? … Or was that just the patient’s own asthma getting worse? How much did the fluid contribute to that?”
There is still a degree of judgment, even there, she says, “but as much as possible we wanted to come to consensus at least about our definitions, our terminology, and our categorization.”
The second barrier to performing this research is the real or perceived risk of litigation. There was a lot of concern at the beginning of her study, says Dr. Chaudhry (and again at the time of publication), regarding the aftermath of disclosing errors.
“As much as the Institute of Medicine and other accreditation and safety organizations talk about how error reporting is so important and that physicians have to be willing to come forward with their errors, there are really no formal, legal, protective mechanisms in place,” she says, adding that this was true three years ago, and she does not believe much has changed.
Consequently, when constructing the study, she reached out to the authors of other error studies and asked them how they had handled the risk of potential litigation. Most of them told her they did not think there was much risk of being sued, but disclosing errors in the literature is certainly not something an institution or individuals would be clamoring to do. If a multi-center study of this nature might be undertaken, she says, these barriers could be traversed and it would be worth it. “Because if we let that opportunity slip through our fingers, it will be taken on by nonphysicians,” she cautions, “by the external reviewers, by the accreditation organizations, by professional quality control people.”