A sea of pimples and drooling yawns. That’s what was staring, glassy-eyed back at me.
More realistically they were staring through me—through space, actually—to 50 minutes into the future. The look inhabited the hinterlands between boredom and loathing. A less-trained eye would mistake their tranquil countenances as anticipatory rapture. However, years of educating medical students and residents taught me that this was the look of those residing serenely in their own world, eons away from the classroom.
Then the ring of the first-period bell jolted me from my thoughts.
It was 7:45 a.m., and I found myself back at my hometown high school—jettisoned 20 years back in time. Months earlier I had agreed to teach a health and biology class as a visiting teacher as part of a career-planning program. I was instructed to teach them about what I do in my professional life. At the time I foolishly imagined a cohort of eagerly engrossed students hanging on my every word. What I found was more in line with a pack of sedated sloths sleepily hanging from the tedium tree.
My folly became even more obvious when I introduced my title slide: “The Epidemic of Medical Error.”
What was I thinking trying to teach 14-year-old kids about patient safety and medical error? Months before the talk I had agreed to this topic only after the principal assured me this would be of great interest to high school freshman and sophomores. It wasn’t until the week before the talk that the unease set in.
Could I really interest hormone-raged pubescent teenagers in the intricacies of hospital patient safety? My wife, ever helpful, was instrumental in triggering this epiphany. She noted that 14-year-olds are really only interested in … well, nothing. The prospect of engaging them in the complexities of hospital healthcare seemed about as likely as getting a trout excited over a fish fry.
Engaged they were not; in fact, some narcoleptic kid in the back had already engaged REM sleep. I was only four minutes into this and I was already foundering miserably. I had become that teacher. You know the one. He is so exceptionally mind-numbing that you wonder if he was brought in as some sort of social experiment testing the currently known limits of boredom.
Then someone had an, er, gastric accident.
The ensuing hilarity made it difficult to pinpoint the exact source or even if this was a true gastroenterological event or its ever-comical cousin, the armpit version. Now, I’m young enough to remember the comic genius of well-timed and executed classroom flatus. As such I understood that this was clearly intended as a territorial marking. The natives had spoken; there was an enemy among them.
As the clock metamorphosed into one of those melting Dali timepieces, we commenced discussion of three cases. The first involved a man who had the wrong leg amputated. The second reviewed the case of young women who suffered devastating consequences after an ICU medication was dropped off her medication list upon transfer to a medical ward team. The final case involved a patient with a myocardial infarction who did not receive aspirin upon admission to the hospital.
An interesting thing happened after I presented the first case. They were interested. It seems cutting off the wrong leg resonates with high school students. Moreover they were aghast that these types of medical errors were occurring. They were shocked that such smart people could make such dumb mistakes. Mr. Narcolepsy slid out of stage 1 sleep long enough to sarcastically note that even he knew that heart attack patients should get aspirin.
I asked them how they thought we could avoid these mistakes. A girl in the front wondered if we couldn’t just ask the patient which leg they wanted cut off. I noted that patients are anesthetized when we meet them for the surgery. She then proffered that perhaps we could ask them while they were awake and then mark the correct leg with a marker prior to going into the operating room.
Regarding the ICU transfer patient who had a medication drop off her med list, a quiet kid in the front asked, “Why don’t you just compare the list of medications used in the ICU to those outside of the ICU?” Another suggested that the two different teams of doctors could sit down and discuss the patient’s medications to be sure nothing was left off.
They wondered if we could avoid forgetting important medications—such as was done with the aspirin for the MI patient—by making a list of the things every patient with a heart attack would need. For example, didn’t they need an EKG, some lab tests, and some medications? Wouldn’t it be best to just have this list so that we didn’t have to remember all these things?
Unwittingly, these teen-agers—none old enough to shave—had just in their own words recited some of the key tenets of the patient safety movement:
- Active communication with the patient prior to surgery;
- Time out prior to surgery to ensure correct patient and surgery;
- Marking the site of surgery;
- Improved communication around patient handoffs;
- Medication reconciliation at every transfer of care; and
- Use of protocols to ensure best practices.
I was floored. In 30 minutes, a group of teenagers had developed a list of hospital safety measures that it has taken modern medicine generations to grasp.
The amount of medical errors has risen in step with the complexity of the medical care we provide. However, this does not mean that the causes of these medical errors are complex. Rather, most errors result from simple mistakes and systems issues. In fact, as I was taught on that fateful spring morning, I learned everything I need to know about patient safety in high school. TH
Dr. Glasheen is associate professor of medicine at the University of Colorado, Denver, where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.