A cascade of errors

At the ACOG meeting last May, Dr. Robert Wachter talked about a case in a teaching hospital in which two women with similar names -- Jane Morrison and Joan Morris are the pseudonyms assigned to them -- were confused with one another, resulting in one of them receiving an invasive procedure intended for the other one. This case did not involve a birth story, but every medical specialty can take lessons away from it.

This case, which Dr. Wachter and colleagues published as "The Wrong Patient," in June, 2002, in the Annals of Internal Medicine, demonstrates how easily a series of oversights can cascade into a shocking medical error. (It could have been worse. The procedure was a cardiac electrophysiology study, not, say, a leg amputation.)

In fact, the team that analyzed the mishap identified 17 junctures at which the process could have been stopped but instead moved forward. No single mistake would have been enough to keep this juggernaut moving. Human error fed into institutional weaknesses, including "frighteningly poor communication," a lack of standardized protocols and a culture that had become sufficiently dysfunctional that more than one person thought, incredibly, Gee, this doesn't seem right, but I'm going to do it anyway.

"Human performance can beimproved but not perfected," the team concluded. Protocols must be in place to head off the inevitable errors before they converge into tragedy.

Medicine too complex to be error-free

I notice that the American College of Obstetricians and Gynecologists is gearing up for its annual clinical meeting May 15 through May 19 in San Francisco.

The 2009 annual meeting was in Chicago, and I attended as many sessions as I could -- I don't want my ideas about what is going on in obstetrics to stop with my own birth experiences. (Sadly, I won't be able to attend the San Francisco meeting.)

I learned a lot last May, but one thing stayed with me in particular, Dr. Robert Wachter's keynote address.

Dr. Wachter,  chief of the medical service at the University of California at San Franciso, among other titles, is one of the founders of the hospitalist movement, and an expert in patient safety.

He spoke about efforts to improve safety since 1999, when the Institute of Medicine released its landmark report,To Err Is Human, which revealed that as many as 98,000 people were dying from medical mistakes every year.

Dr. Wachter's message is important for the birth story because obstetricians are the doctors most often sued for malpractice. A 2003 ACOG survey showed that 76 percent of OB-GYNs have been sued at least once.

Many of them would say that if anything ever goes wrong with a birth, they are sued whether the mishap was their fault or not. Dr. Wachter agreed that "the blame game" is "not productive."

He said, "Medicine is too complex to be error free." Some other complex industries have better safety records, though, he said, often because they have developed "systems thinking," standardizing procedures and accepting that some mistakes are a natural part of the process.

 

Informed reporters an endangered species

I have seen a couple of blog posts lately grousing that the "mainstream media" is choosing not to cover this or that event or development, as if to suggest that a conspiracy is afoot to keep people in the dark on a particular topic.

As a staff writer for the Chicago Sun-Times, I am a member of the mainstream media, and I wonder if people have a good sense of what's happening in our industry. Ad revenues have been dropping, mostly as a result of services available on the Internet, and hordes of writers and editors have been bought out or laid off in recent years.

Fewer bodies mean less time per project -- less time to learn about a new topic, and often no time to take on a tough topic.

Just for example, I have seen complaints that many important aspects of childbirth, the topic I address here in Birth Story, don't get the attention they deserve in the media. I couldn't agree more, but I also know that a good airing of the issues would require a depth on the bench that simply isn't there at most media outlets right now.

The Tuesday Science section of the New York Times is one of the rare dedicated sections left that cover science and health. Natalie Angier, a Pulitzer Prize-winning writer for the Times, said she has noticed that that section addresses health topics more than science ones these days, in a story posted by Mallary Jean Tenore on the Poynter Institute's website.

Readers appear to want stories that relate directly to their own lives, said Angier, who has written a number of science books, including Woman: An Intimate Geography. Her latest is The Canon: A Whirligig Tour of the Beautiful Basics of Science.

"One of the things I try to do when writing about science is make it seem like it's part of your life already by making things into characters and protagonists, even if they're just molecules," she said.

Charles Petit, chief tracker for the Knight Science Journalism Tracker, agrees that strong articles on science topics are becoming scarce.

While such issues as stem cell research and global warming still appear on newspapers' front pages, they are less likely to be written by reporters who have a solid understanding of those topics. So the stories are superficial, and readers don't get what they need to understand them, Petit told Tenore.

Even scientists are worried about this trend. In a Pew Research Center study published last year, nearly half of scientists polled said oversimplification of scientific findings in the media is a major problem. A whopping 85% of scientists said that the public’s lack of scientific knowledge is a major problem for science.