Medical error is the third leading cause of death in America. Miscommunication between medical practitioners themselves, and between them and their patients can lead to life-changing outcomes for patients and their families.
One person who's working to change the prevalence of medical error is Dr. David Mayer. He's a cardiac anesthesiologist by trade. Two decades ago he started questioning why his hospital’s leadership wasn’t tracking the failure and success rates of procedures or infection rates in his department. It was only when the Institute of Medicine first released a report on medical errors in 1999 that hospitals, including Mayer’s, began to take notice.
Mayer has since co-founded the University of Illinois Institute for Patient Safety and is now the executive director of the MedStar Institute for Quality and Safety. He's also the CEO of the Patient Safety Movement Foundation.
His current efforts include implementing safety and communication programs for hospitals. And he admits it's been a real challenge to change culture in health care.
“I believe from day one, I said this when I was tired and jet-lagged, but I stuck with it — that the way you change culture is to educate the young and regulate the old," Mayer says. "When I said that, I got about 50% who applauded and 50% who hissed.”
Health care and hospitals are large, complicated systems in high risk environments. And while there are amazing advancements in medicine, Mayer says a key problem in accountability when dealing with medical harm is that hospitals fear transparency — or simply lack it.
"Not only do we have a medical harm crisis, but then when harm occurs we follow the old 1960s and '70s model — delay, deny and defend," he says.
Lawsuits, litigation and bad public relations are the biggest fears hospitals face when medical error occurs. However, Mayer notes that policies, such as CANDOR (Communication and Optimal Resolution), have shown that open and honest communication after a preventable medical harm isn't just the right thing to do, it's the smart thing to do.
"We don't see the lengthy litigations, we don't see the drag-outs ... and most importantly these organizations are learning from it and improving their systems," he says.
The Burrows family, featured in the HBO documentary Bleed Out, is proof of medical error gone terribly wrong. Judie Burrows went in for a routine hip surgery at the Aurora West Allis Medical Center that resulted in a nearly two week coma that led to permanent brain and physical damage.
Mayer says the Burrows' family story is incredibly important to share to raise awareness about medical error. But he also points to the case of Jack Gentry to show how accountability after medical error made the best out of tragedy.
Mayer says that while we're not "at the tipping point ... we're seeing more and more hospitals and more and more liability carriers starting to embrace this [transparency] model."
But what can you do when you need to go to the hospital? Mayer suggests that you have an advocate by your side and do your research on hospitals if you're able to before a scheduled procedure.
"It's been shown that patients do better when they've got an advocate there with them that's asking questions and confirming things with the nurse, the physician for that patient," he explains.