Several people have recently told me quality of care stories, and one nursing group sent me a list of 25 Tips to Help Protect Yourself from Medical Errors. The common theme for all these is that to help avoid errors, the patient (or their family) should make sure they are informed about their condition and treatments, and they need to develop relationship with clinicians that enable good communications.

The first case is a friend’s father who, after suffering a spinal cord injury, is living in a nursing home/rehabilitation facility. Cognitively he had been doing great – 80+ years old and did his own taxes this year.  Over the course of a couple of days he became much sleepier, stopped eating much, and just “wasn’t himself.” It was up to his wife, daughters and son to initiate prompt attention to his situation. Possibly because his son is an ER physician, this attention came sooner, and the good news is that after some not too complicated medical treatment, he is doing much better, eating, more awake/aware, and back to his regular self.

One of his daughter noted that the staff of the facility should have noticed the changes. But she also recognized that many of the other patients in the facility are much less engaging and alert than her father, so his changed alertness, etc. might not have seemed abnormal to them. She also noted that since many families don’t have physicians to directly raise questions, then similar problems might not be addressed as quickly as her father’s, and this could lead to bad outcomes. This ‘knowledgeable squeaky wheel gets the oil” is probably an unfortunate reality of our healthcare system – and probably other parts of our society as well.

The second situation was more systematic, and involved the possibility that some of the innovations we are looking for to improve the quality of care, are not without their own pitfalls. One example of this was brought to my attention by an old friend, and involved the use of computerized order entry systems (CPOE) in hospitals. These systems are becoming quite common (Massachusetts is in the midst of an initiative to install them in every hospital in the state), and have been shown to reduce medication errors from bad handwriting, and missed drug-drug interactions and allergies.

However, like many tools, CPOE systems can also breed their own sources of errors. My friend told me how such a system had resulted in one patient receiving a large overdose of narcotics. The problem that led to this occurring was systemic in that the CPOE system had enabled the large dose to be automatically ordered for the wrong patient, and because many patients on the floor were receiving large doses of narcotics the nurses did not perceive this as unusual. Fortunately, the situation was addressed and the patient was fine.

The overarching principle here is that quality of care is a great goal, but technology is only part of the solution. As Drs. Groopman and Hartzband concluded in their recent New England of Journal perspectives piece about electronic medical records (EMRs), “We need to make this technology work for us, rather than allowing ourselves to work for it.”

I completely agree with Groopman and Hartzband, and usually state this the principle more directly as, “Make the technology work for you, don’t work for the technology.” (I suspect that we both heard something like this first somewhere else.)

What are the most common or serious reasons for quality of care problems you’ve seen? And how often has patient-physician mis communications contributed to the problem?