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HOUSE CALL WITH DR. SANJAY GUPTA

"Preventing Medical Errors"

Aired July 31, 2004 - 08:30   ET

THIS IS A RUSH TRANSCRIPT. THIS COPY MAY NOT BE IN ITS FINAL FORM AND MAY BE UPDATED.


(BEGIN VIDEOTAPE)
SANJAY GUPTA, HOST (voice-over): Starting this month, hospitals are adopting procedures aimed at reducing medical mistakes in the operating room. It's simple as a checklist, the same kind pilots have used for years.

Mary Hahn is getting a total knee replacement at Emory University hospital in Atlanta.

MARY HAHN, SURGICAL PATIENT: I was just going to put an arrow down there and I wanted to write, wrong knee. But they said I can't do that.

GUPTA: Mary marked her knee with her doctor's initials the night before surgery.

According to new federal rules, the doctor, not just the nurse, must now check with the patient to confirm the type of surgery and the surgery site.

DR. JAMES ROBERSON, ORTHOPEDIC SURGEON: Put my initials on, just below where you marked it.

GUPTA: Then a nurse makes sure again, they have the right patient.

UNIDENTIFIED FEMALE NURSE: First off, can you tell me your name?

HAHN: Mary.

UNIDENTIFIED FEMALE NURSE: OK.

GUPTA: And the right procedure.

UNIDENTIFIED FEMALE NURSE: And Ms. Hahn, what are you having done today?

HAHN: Right knee.

UNIDENTIFIED FEMALE NURSE: OK.

GUPTA: Then before the surgeons make the first cut a time-out is taken, where the whole surgical staff verifies a third time that they have everything right.

UNIDENTIFIED FEMALE NURSE: It's the right knee you have prepped. Everybody on agreement?

UNIDENTIFIED MALE: Yes.

UNIDENTIFIED MALE: Yes.

GUPTA: Surgical checklists are not new, bought national standard is. And doctors are optimistic that it will help bring medical errors down.

ROBERSON: I love it. I wouldn't practice without it. It's very reassuring to me to be able to glance down at the patient's extremity, and see initials there, that confirm that I'm doing a correct thing and not the wrong thing.

GUPTA: Still, doctors realize that medicine, a very human profession, will always be vulnerable to mistakes.

ROBERSON: There are a lot of steps in this process. And there are a lot of humans involved, and there's always room for human error.

GUPTA: For Mary, the new O.R. checklist, and her own involvement in her care gives her peace of mind.

HAHN: You feel a little more in control of the situation. Because you lay there thinking oh, I hope they get the right knee. But this way, if it's marked, it's going to be right.

(END VIDEOTAPE)

GUPTA: And getting it right is certainly the goal of all medical professionals. But to quote a federal report done on medical mistakes, "to err is human." It's been five years since that report made headline, saying as many as 98,000 people die every year from medical errors. So where do we stand in this fight to cut down on the errors?

Let's find out from Dr. Robert Wachter. He's the associate chairman of U.C. San Francisco's Department of Medicine and the editor of an online patient safety journal. Plus, just this year, he co- authored a book "Internal Bleeding, The Truth Behind America's Terrifying Epidemic of Medical Mistakes." Welcome, doctor.

DR. ROBERT WACHTER, CO-AUTHOR, "INTERNAL BLEEDING": Thank you, Sanjay. Great pleasure to be here.

GUPTA: I read the book. I've got say it's a terrific book and a little frightening as well.

WACHTER: Well, the problem is frightening. And we tried very hard to be dramatic and interesting, because the problem really is that. But also, to be truthful and honest, and to be helpful to try to outline some of the solutions we need to embrace to fix this.

GUPTA: Yes. You know, I mean people really pay attention to these numbers. The report that we quoted, 98,000, that number's actually increased now to nearly 200,000 people dying every year and in another report due to medical errors. From hearing those numbers, it sounds like we're actually taking a step backwards. What do you think?

WACHTER: Well, the recent report that just came out last week was not a very, very good study. And I think the best answer is, we don't know for sure. There's a lot of debate about the numbers. But I think the truth is this, Sanjay. That if it's about 98,000 Americans a year dying, that's a jumbo jet crashing every day. Whether it's one jumbo jet, two jumbo jets or a Greyhound bus going over the guardrail every did, it's still is a big, important problem that I think we all have to admit in medicine; that we had not paid a lot of attention to until about five years ago.

WACHTER: Well, and we're going to try to give viewers some real practical advice to try and bring those numbers down, because it is the viewers' responsibility, a patient's responsibility, a doctor's responsibility, all of that.

Let's do that by getting to viewer questions. Our camera went out on the streets. Take a listen to this first question.

(BEGIN VIDEO CLIP)

UNIDENTIFIED FEMALE: I would want to know if I should mark the knee that's to be operated on as, "This is it" type thing? And the one that's not to be operated on as, "No?"

(END VIDEO CLIP)

WACHTER: It sounds like a pretty basic thing, Doctor, right? Just marking your knee, so that you tell the doctor which knee you need to operate on? Does it work? And should you mark the knee that's not supposed to be operated on, or the knee that's supposed to be operated on?

WACHTER: Well, Sanjay, as you know, the -- it turns out to be a little more complicated than anybody thinks. In the early days of people marking the site, some patients put, as the viewers suggested, put the word "On." Or put the word, "No." If you look at the word "No" upside down it says "On." Some surgeons began marking an X on the leg to be operated on, as in X marks the spot. Others began putting an X on the leg not to be operated on, as in don't operate here.

So what we really needed was to not have the Wild, Wild West and have a single way of doing it. And I think what we've all settled on is surgeons initialing in the patient's presence, putting their own initials on the leg to be operated on. I think we need to do it the same way every time, at every hospital with the patient involved. And I do think that will markedly decrease the rate of wrong leg or wrong arm surgery hopefully to zero.

GUPTA: And patients really want specifics advice like that. And there are steps you can take before you ever get into the hospital to ensure a safe stay. First, make sure the hospital you're visiting is accredited. And check to see how many operations like yours have been performed by your doctor and that hospital. Studies have shown that the more the procedures is done, the fewer mistakes.

Also, find out if you have to stop taking your medicines before treatment. And write down any questions you have before going. After all, you may be too nervous or medicated the next time you see your doctor to remember any of those concerns that you might have. Along that same line, ask the hospital or doctor questions you have about your discharge instructions before you go for treatment, since you may be feeling a little woozy or something like that when you're discharged. And lastly, bring a friend. They can offer support and ask any questions that you may forget.

We've got a question now coming from Rebecca in South Carolina, who asks, "What should be done to designate an advocate, such as a friend, to be responsible for questioning and with discussions of care?"

Is this a formal process, Dr. Wachter, establishing an advocate?

WACHTER: Yes. There is something called an Advanced Directive. And patients now actually -- it's mandated that they be given the opportunity to designate someone like that when they come to the hospital. But I think it's a great idea to do that when you see your doctor in the office.

Now, it's important to recognize that that person, you speak for yourself, but if you ever lose the capacity to speak for yourself, you're a little bit groggy after surgery or it's the middle of the night, and we need to talk to someone about what you would want done. We can go to that person.

And I think, as you say, in your suggestions, having somebody with you, if you can to ask questions. Be sure that they're -- that it's you that they mean to be giving the medicine to, or that you're the right person to go to the procedure. I think that's all very, very helpful.

GUPTA: We're talking to Dr. Robert Wachter.

Let's get to another question. Michael in West Virginia wants to know, "How does a person go about evaluating his doctor skills and surgical success rates? Are there physician referral and rating services?"

Doctor, you must get asked this all the time. And there's little information out there really about doctors. How do you get that?

WACHTER: Well, as you know, it's kind of hard right now. I think that there is a vision that in the next several years, you'll be able to go to the web, or other sources, and find out as much as your doctor, as can you find out about your car when you read "Consumer Reports."

The problem is it's a little bit complex. So as you know, Sanjay, from the kind of work you do, if a doctor happens to take care of the sickest patients, their outcomes may not be as good as another doctor who takes care of easier patients, even though they're really, really quite skilled.

So where still the science of rating doctors is still in its infancy. I think we'll get there. Right now, I would be focusing more on how many of the procedures the doctor does. How many procedures the hospital does. And then whether there are certain basic things that the doctor does. And I think they'll start getting that kind of information. Does the doctor give the right medicines for a patient with a certain procedure? Does the hospital have computerized order entry and bar coding? Those sort of things, I think people are going to be able to get the information they need.

GUPTA: You make a good point. Sometimes those doctors who do the most difficult procedures get an unfair rap.

We're going to be taking more of your questions after the break. Stay tuned for more HOUSE CALL.

(BEGIN VIDEO CLIP)

UNIDENTIFIED FEMALE (voice-over): What steps can you take to make your visit to the hospital safer? We'll give you some easy to follow tips.

And later...

DR. CHRISTINA DERLETH, INTERNAL MEDICINE INTERN: I was on a call on the very first day. And it was terrifying and horrifying, and I was exhausted.

DR. JOE MILLER, CARDIOLOGIST: How about that other gentleman?

UNIDENTIFIED FEMALE: We'll take you inside a teaching hospital...

MILLER: Is he doing all right?

UNIDENTIFIED FEMALE: ... where summertime means new doctors are on the front lines.

High are you doing?

UNIDENTIFIED FEMALE: Could their inexperience put you at risk?

Before we answer that question, try and answer our "Daily Dose" quiz. Which hospitals have fewer medical errors overall? Teaching hospitals or non-teaching hospitals? The answer, when we come back.

(END VIDEO CLIP)

(COMMERCIAL BREAK)

(BEGIN VIDEO CLIP)

UNIDENTIFIED FEMALE (voice-over): Checking the "Daily Dose" quiz, we asked which hospitals have fewer medical errors overall? Teaching hospitals or non-teaching hospitals? The answer, according to a new Healthgrades study, teaching hospitals had slightly higher numbers of errors.

(END VIDEO CLIP)

GUPTA: If the Centers for Disease Control listed medical mistakes in its annual listing of leading causing of death, they'd be No. 6. That's ahead of diabetes and Alzheimer's. To help reduce these errors, the government announced plans to create an electronic health system. But here's the catch, there's no money lined up at this point. So the plans may still be years away.

Until then, some patients are doing something dramatic. They're taking their own medical records and putting them in their own hands on CDs and microchips. We're going to be talking more about that in a few minutes.

But talking to us now is Dr. Robert Wachter. He's an internist and hospital safety expert at U.C. San Francisco. He also chairs the Patient Safety Committee there.

Now, Doctor, lots of e-mails lined up. Let's get to another one right away from Doug in Wisconsin who wants to know, "What kind of role do you think these electronic medical records will play in reducing medical errors in the future?"

And you know, you and I have talked about this, Dr. Wachter. Medicine is ultimately a very human profession. Is the technology going to really help?

WACHTER: It's going to help tremendously. It will never make it an un-human profession. That's right. But right now, the fact that you and I transmit our wishes through our own handwriting, at least I know mine is not very good, is not the way to go. By 10 years from now, we need to have every hospital in the country computerized. It will make care much, much safer. GUPTA: Is that going to happen?

WACHTER: I think so. I think it's going to become -- I think we're going to have a tipping point fairly soon, where a hospital is not going to be able to say we're a high quality hospital, if the doctors are still writing their orders with handwriting. And it's more important than just handwriting. There will also be decision support; best practices will be integrated into the computer system. So it will guide the doctors into knowing the right medicines, for example.

GUPTA: One of the most common mistakes that can happen in a hospital or even at your local pharmacy is the misreading of a prescription, like Dr. Wachter was talking about.

We've got a question on that topic now from Joshua in California, who asks, "What are hospitals doing to prevent prescribing the wrong medication?"

And Doctor, in your book, which I read, you gave an example of a prescription mistake. Let's take a look and maybe you can talk us through this. There is the prescription; messy handwriting, just as you say. First of all, what you -- is that -- what do you think when you look at this prescription?

WACHTER: Well, it's scary because I can't tell what that is. And we actually did a survey of about 160 doctors, asking them if they could tell what that was a prescription was for. The choice is whether it was a prescription for a drug called Plendil or a drug called Isordil. This was a real prescription given to a man in Texas in 1995.

GUPTA: And the viewers at home right now are making their bets right now. What did you think it was?

WACHTER: Good luck. I thought it was Plendil. The pharmacist thought it was Plendil. He gave the patient Plendil, it turned out it was for Isordil. And that was an eight-fold overdose. And tragically that man died.

GUPTA: Wow. Oh, my gosh. And these seem like pretty simple mistake, just handwriting mistakes. What can you do to prevent these types of things?

WACHTER: Well, in the longer term, it's all going to be about computers. In the shorter term, there are all of these Latin initials that you and I learned in medical school that need to go away, because they're confusing. And doctors are now being forced in some times -- in some ways by regulators to stop using some of these high-risk abbreviations.

I guess what I recommend the patient to do, especially in the office, if you're given a prescription take a look at it. And be sure you can read the word and you can read the numbers. You may not know the Latin, but if you can't read it, there's a chance the pharmacist might not be able to either.

GUPTA: All right. Really good advice.

Now, when HOUSE CALL returns, new doctors hit the halls of a hospital near you. Could their learning curve hurt your health?

(BEGIN VIDEO CLIP)

UNIDENTIFIED MALE: Wow. I'm really a doctor. I'm not playing doctor anymore. This is it.

UNIDENTIFIED FEMALE (voice-over): Some say July is the most dangerous month for you to go to the hospital. We'll tell you why, and if it's true.

Plus a popular cholesterol drug goes over the counter in the U.K. We'll give you details. Stay tuned.

(COMMERCIAL BREAK)

GUPTA: Welcome back to HOUSE CALL.

Get sick in the month of July and some people will beg not to be taken to a teaching hospital. That's because that's the month where medical school graduates begin their training programs. We took a look at whether those fears are founded.

(BEGIN VIDEOTAPE)

GUPTA (voice-over): On the hit TV show "ER," it's not unusual to see new doctors making mistakes.

(BEGIN "E.R." CLIP)

UNIDENTIFIED FEMALE: She needed constant monitoring.

UNIDENTIFIED FEMALE: I was supposed to check her every 15 minutes.

(END "E.R." CLIP)

GUPTA: New doctors are more common in July. Fresh out of med school, they flood teaching hospitals across the nation.

UNIDENTIFIED MALE: How about that other gentleman? We're coming to see him.

GUPTA: Overnight, they go from being medical students to doctors called interns. And they make some people nervous to be patients in teaching hospitals in July.

Dr. Christina Derleth remembers her first day on the job at Emory Hospital in Atlanta. That was just two weeks ago, and she was nervous as well.

DERLETH: It's very scary. Nothing changes from one day to the next, except for your title. And all of a sudden you're expected to be responsible. It makes you nervous, but the supervision here has been very good.

GUPTA: Supervision is the key when it comes to nervous new docs. Everybody's watching from the nurses.

JANE THOMAS, REGISTERED NURSE: They always ask us to look at the orders. Do you see anything that we've left out? Can I, you know, add anything?

GUPTA: To the attending physicians.

DR. JOYCE DOYLE, RESIDENT DIR., INTERNAL MEDICINE: They are never alone. They always have a lot of hands-on supervision with everything they do.

GUPTA: To the new doctors themselves.

UNIDENTIFIED FEMALE: That's what residency is about, is having someone there, so that you can ask those questions and get the right answer to it.

GUPTA: Studies don't back up the rumors that teaching hospitals are unsafe in the summer. A large study published in the "Journal of General Internal Medicine" found no significant difference in the mortality rates or lengthens stay at teaching hospitals from July to September. Ironically, most doctors we talked to think you might be safer having surgery in the summer.

DERLETH: We're going to double check everything we do. Because supervision is higher because they know we're new.

MILLER: So we're watching what they do. But they watch what we do too. I mean, you know, I mean they're quick to point things out if we've forgotten something.

GUPTA: Meaning a teaching hospital might not be such a bad place to go. You get a good mix of the seasoned doctor, and the inquisitive new kid on the block with the most recent medical school knowledge.

(END VIDEO CLIP)

GUPTA: And trying to increase our knowledge of avoiding medical errors, is Dr. Robert Wachter. He's the chief of medical services at U.C. San Francisco Medical Center, and co-author of the best selling book, "Internal Bleeding."

Doctor, besides all the supervision these new doctors are getting, there's also a new rule in place. I know you know it well. Mandates they work no more than 80 hours a week. Is this still too much? That's a question that a lot of people are asking.

Here's an e-mail from Ashland in Pennsylvania who writes, "Watching the sleep deprivation my husband has experienced during residency," you and I both know it well, "coupled with the fact that errors are more likely to occur in times of sleep deprivation, why have work hours only been limited to 80 hour work as opposed to 60 or 40?"

Dr. Wachter, is this an arbitrary number or is there some science behind this?

WACHTER: There is very little science behind it. There are no data to say what the right number is. There is a fear. And I think it's legitimate that if we cut the hours too much people won't learn enough. And the problem -- the biggest problem, Sanjay, is every time we cut the hours we build in more transitions. More handoffs of patients from one group of doctors to another, and that carries its own risk.

So whether it's the right number, 60, 70, 80, I'm not sure. I know when I trained and I know when you trained, it was more like 100 or 120.

GUPTA: Right.

WACHTER: That wasn't good for anybody.

GUPTA: No. It wasn't. One thing to point out. A lot of people don't talk about fact that that 80-hour rule doesn't apply to nurses. A new study found one-third of nurses -- they followed worked overtime every day during the four-week study. That overtime can be costly. Researches say the likelihood of making an error was three times higher when nurses worked shifts lasting more than 12 hours.

Now, Doctor, we know there's a nursing shortage. How big of an impact would this have on patient care and mistakes?

WACHTER: Well, nurses really are the -- they're the people that keep patients safe. And if there are not enough of them, or if they're overstressed, or their shifts are too long, then I think that's in some ways a greater risk to patient safety than anything the doctors can do. So it's really very important. In California, there's now a law that mandates a certain ratio of nurses to patients. And I actually think that's very healthy.

GUPTA: And you and I both know we couldn't do those jobs without the nurses.

WACHTER: Absolutely not.

GUPTA: Now listen, we're not done yet. When question come back, this week's top medical headlines.

(BEGIN VIDEO CLIP)

UNIDENTIFIED FEMALE (voice-over): Could long-term use of a popular painkiller end up hurting you? We'll bring you a new study next.

And looking for a way to find a certified hospital near you. Or just more tips to prevent medical errors. Stay tuned for more information.

(END VIDEO CLIP)

(COMMERCIAL BREAK)

GUPTA: Welcome back to HOUSE CALL.

Let's take a look at this week's medical headlines in today's edition of "The Pulse."

(BEGIN VIDEO CLIP)

HOLLY FIRFER, CNN CORRESPONDENT (voice-over): Over the counter sales of the popular cholesterol-lowering drug Zocor, will begin this week in the U.K. But patients will not be able to buy the drug without talking to a pharmacist. British pharmacists have been advised to only sell Zocor to patients with a moderate risk of heart disease and recommend that those with a higher risk consult a doctor.

Also, long-term use of acetaminophen found in Tylenol, Excedrin and other over the counter products may harm your kidneys. A new study published in the "Archives of Internal Medicine" followed close to 1,700 middle-aged women and found that those who took large amounts of the drug increase their risk of kidney dysfunction. The makers of Tylenol claim that the new study contradicts other research, which proves the drug is safe.

Holly Firfer, CNN.

(END VIDEO CLIP)

GUPTA: Thanks, Holly.

For more information on avoiding medical errors, go to the Agency for Health Care Research and Quality. That's at www.ahrq.gov. There you're going to find tips for consumers on everything from prescription safety to hospital care. Also try www.jcaho.org. Click on "General Public" and you're going to find five detailed steps to safer healthcare. Also on that site, click on "Quality Check" and you can compare accredited hospitals in your own area.

We've been talking to Dr. Robert Wachter. Doctor, lots of good tips today, doctor. What's a final thought you'd like to leave with our viewers?

WACHTER: Well, Sanjay, this can be an awfully depressing topic. But let me reassure your viewers on two fronts. The first one is that when you go to the hospital chances are you're going to be find. That American hospital care by and large is terrific.

The second is you should know that we're really working on this very hard. We called our book "Internal Bleeding" because this was a silent epidemic at for a long time. But it's not silent anymore. We're open about and we're really working on it. And I think we're going to get this thing fixed.

GUPTA: Well, thanks so much, Doctor.

We're out of time for today. Thank you, Dr. Wachter. Thank you at home, as well, for all of your questions.

Tune in to CNN this week. We're going to show you a new device that could be a last resort for those suffering from depression.

We're also going to bring you up to speed on the story of Philippino twins due to be separated on Wednesday in New York.

Remember, this is the place for the answers to your medical questions, all of them. Thanks for watching. I'm Dr. Sanjay Gupta. Stay tuned now for more news on CNN.

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