To Err Is Human. While this vulnerability is universally recognized, the repercussions and social stigmas vary depending upon the paradigm of that error. Almost two years ago, Dr. Jason M. Kane, a Pediatric Intensive Care Specialist and the Patient Safety Officer for the Department of Pediatrics at Rush Children’s Hospital at Rush University Medical Center in Chicago, Illinois approached me to collaborate on a writing project that delved into the multi-faceted error-prone medical system addressing:
1) Patient safety
2) The psychological and economic consequences of medical errors on clinicians as well as patients
3) The fearful emerging trend of ‘criminalizing a doctor’s errors’
4) The moral crossroads that the medical community faces in their day-to-day work
Certainly, this isn’t the first time we’ve heard of patient safety being compromised. There have been numerous books written about the fallibility of the medical system, articles, PSA’s and even documentaries. AARP recently featured an extensive overview on, “How to Protect Yourself from Hospital Errors – Patient Safety.”
For over two decades, many high profile stories have tried to raise awareness of the human impact of medical errors and yet these medical system errors relentlessly persist at a rampant rate. Approximately, 100,000 patients die unnecessary deaths each year from preventable medical errors, more than breast cancer - more than motor vehicle accidents. (CDC; Center for Disease Control)
Beyond the cost in human lives, preventable medical errors exact other significant tolls. Medical errors have been estimated to result in total costs (including the expense of additional care necessitated by the errors, lost income and household productivity, and disability) of between $17 billion and $29 billion per year in hospitals nationwide. (Agency for Healthcare Research and Quality)
Kane explains: “In today’s economic climate, a reduction in medical errors could help stem the tide of out of control healthcare spending. Errors also are costly in terms of loss of trust in the health care system by patients and reduced satisfaction by both patients and their physicians. Society bears the cost of errors as well, in terms of lost worker productivity, reduced school attendance by children, and lower levels of population health status.”
Kane emphatically insists that the statistics of these particular medical errors aren’t the result of careless clinicians or negligence. These errors are not the result of malpractice. “The medical errors that are most harmful are those that are quite simply the result of system failures, errors that even the most careful clinicians were unable to prevent,” he says.
A frustrating aspect “is that we have seen the same issues arise in other high-risk industries, but unlike medicine, those industries have aggressively and publically acted to reduce incidents and harm.” He provides the following example. “How many airplane crashes in a single year would it take before the entire airline industry would require a safety overhaul? The number of patients killed by medical error is equal to a commercial airliner crashing every day for nearly an entire year.” He continued: “Think of the safety records of the railroad industry, or the nuclear power industry, and the degree of public and governmental scrutiny required to ensure safety.”
He rhetorically asked: “Why has the medical industry not taken, as hard, if not a harder line on patient safety?”
He upholds: “Quite simply, the largest reason is that in air traffic, or railroad, or nuclear power, the largest driver for safety was and still is the public. There has yet to be a similar outcry from patients and the general public with respect to ensuring the safety while receiving medical care.”
“And it is for this very reason that an alternative approach to delivering the message of the criticality of patient safety is warranted,” he professes.
How do you deliver this message to the masses in an effective way that will not only raise awareness, but also serve as a call for public outcry? Kane suggested a new approach to effectively deliver this message to the community at large. As a result, we created a fictional medium (both film – Code 99 and a television series – Human Error) where these issues are explored with complexly layered characters in ethically challenging situations in hopes that viewers will connect with the characters and storyline and become more aware of the intricacy of the medical system, talk about the issues, gain a broader perspective to the root of medical errors, and ultimately become more proactive in their own patient safety.
Since his 2009 graduation from Northwestern University’s Master’s Program in Healthcare Quality and Patient Safety, Kane has trail blazed many effective patient safety and quality initiatives. While at Children’s Memorial Hospital in Chicago, he helped pioneer the development of a quality improvement program centered on the resuscitation efforts during pediatric cardiac and respiratory arrest within and outside of the pediatric ICU.
Kane also spearheaded a team of clinicians in the implementation of a clinical transition protocol for patients admitted to the cardiac ICU following congenital heart surgery. His fierce dedication for improving the safety of patients has earned him tremendous peer respect resulting in his national peer-nomination and selection to be part of the American Society of Quality’s New Voices of Quality for 2011. (a total of 40 individuals were selected)
Now at Rush University Medical Center as of 2010, Kane continues with his energetic activism in both University and hospital-wide patient safety and quality initiatives.
Kane says: “The medical community is wrestling with and finally starting to get traction in trying to promote patient safety in our own internal system.”
While many hospitals implement positions such as a Patient Safety Officer to help ensure quality standards of care, he says: “It’s absolutely a hurdle for patient safety experts. Some doctors seem reluctant to engage in this sort of dialogue because of what’s being exposed, especially in the context of public reporting of outcomes, and the significant financial implications.”
Hollywood has also been a little reluctant to pick up this story, despite their fascination with the one-of-a-kind raw storyline for both a television medical drama and suspense film. Some execs feel that a network would never pick up our television show, Human Error written as a dark comedy and breaking all rules of linear storytelling, (involving the audience in determining the outcome of the show as a metaphor to engage them in their own patient safety) because they don’t want to see doctors making errors. Another exec informed us that the public doesn’t want to see something like this as well and emphasized that no advertisers will pay for this.
Dr. Kane says: “I think Hollywood is underestimating what the public really wants to see. The transparency of what doctors do when they face these issues is actually a good thing and the idea that the public will be somehow disenchanted by the reality of medicine is patronizing the public in a way that doesn’t do them justice.”
A cast of well-renowned actors, however, have demonstrated no reluctance towards the suspense film Code 99 and are volunteering their talent for an exclusive industry reading on Thursday, April 26th.
This is a private industry performance in the pursuit of taking this storyline to the next level. For those medical professionals, qualified members of the press, or industry executives wishing to experience Code 99, please contact Mordecai Schaeffer at firstname.lastname@example.org