The Wrong Guy

One of the points Dr. Robert Wachter made in his speech at the ACOG meeting in May, 2009, was that everybody makes mistakes. True, people can wind up dead when doctors make mistakes, but everybody else makes mistakes, too.

To illustrate his point, Dr. Wachter showed a video from the BBC, "The Wrong Guy," the tale of two men named Guy who were waiting in reception areas in the BBC's London offices on the same day in 2006.

One was there to interview for a job.  The other, an expert on information technology, had been scheduled to hold forth on the network's News 24 program about a ruling in Apple Corp.'s suit against Apple Inc. The Beatles' music company and the computer firm had previously agreed to stick to their own businesses. But then came iTunes, and Apple Corp. sued Apple Inc. for alleged encroachment on its music brand.

A London judge ruled in Apple Inc.'s favor and the BBC invited tech expert Guy Kewney on to chat about the ruling. But it was Guy Goma, the unwitting job applicant, who was summoned from the waiting room for the interview.

The look on "the wrong Guy's" face when he catches on to who they think he is is priceless!

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.