This is insane and NOBODY talks about it?

An article has been making its way around the medical and lay literature, that should be driving people into the streets, screaming for immediate solutions rather than promises for future improvements.

In a paper published in the British Medical Journal (BMJ 2016;353: i2139), the title reads “medical error – the third leading cause of death in the US”. Statistics on the true effect of medical air on patient health are actually quite limited. When the doctor fills out a death certificate, he will rarely indicate that medical error was the cause of death. Often it is necessary to review massive numbers of charts in order to understand the progress of treatment for the patient and thus identify an error that caused death [let alone unnecessary complications].

To put this number into perspective, more people die from medical errors than respiratory disease, accidents, Alzheimer’s and stroke. The only two diseases that appear to kill more people each year than medical error are heart disease and cancer. Tremendous advances are happening as we speak in relation to heart disease and cancer, and there are those who predict that within the next decade or two, we will have  dramatically reduced the morbidity and mortality from heart disease and cancer. What this means is that it could very well be that within a single generation, the leading cause of death  will be medical error.

Deaths in the US

How is it that no one speaks up about this. How is it that the Surgeon General is not called in, in front of Congress and asked to explain this atrocity. Needless to say, if a car company was to quote a death rate of 250,000 people a year from the use of their automobiles, the company would be shut down forcibly. If the medication given regular lead to people and even children, claimed the lives of 250,000 people a year, the medication would be pulled from the shelves and the producers would most likely be brought up on charges of criminally negligent homicide.

Let me state once again that we are talking about causes of death, versus causes of injury. If 250,000 people a year are dying due to medical error, it is reasonable to assume that a multiple of this number are suffering from complications of medical care. There are unfortunately too many nightmare stories of wrong operations being performed, and the wrong patients receiving dangerous medications. And while these mistakes do not cause death, they definitely rank as horrifying errors in care.

What is astounding is that doctors still claim that the safest hands for treating patients are their own. They claim that even present-day robots, computers and software cannot ever hope to achieve the quality of care that they provide. Doctors are complaining that they are overworked and do not have the time to properly assess and manage their patients. In the same breath, they claim that the doctor-patient relationship is unique and must be maintained, in order to preserve the best quality of care. I am going to make a very blunt statement that doctors either are totally unaware of these statistics, which is absolutely unacceptable, or simply don’t care. Given my own anecdotal experiences, I have no problem believing that patients are dying due to the disk interest of their physicians. I have seen far too many doctors look for shortcuts and care, or not even bother to review the charts of certain patients on a given ward.

As a medical student, I remember one patient who had been admitted for alcoholism. He presented to the hospital in a stupor, and was admitted to effectively to sleep it off. His vital signs were recorded three times a day and were stable. The chief resident of the team I was on, was looking at the chart and decide to pass by the room, assuming that the patient  was still sleeping off his last binge. After three days of such “rounds”, the chief resident decided to go into the room and actually talk to the patient. The patient was dead and had signs of having died three days earlier. Let me repeat that there were recorded vital signs on his charts going back three days.

You may ask what happened to the chief resident and to the nursing staff on that floor. It shouldn’t surprise anyone if I told you that they were all seriously reprimanded and some of them were even fired. Well, that’s not what happened. The patient was alone, had no one to speak for him, and had his time of death marked as being just a couple of hours before morning rounds. The case, literally, was swept under the rug, and yes, the story was related to other doctors in a joking manner.

I should point out that nothing stopped me from going back after rounds to check on the patient. I was a good little rabbit that followed along with my chief resident and accepted whatever he said as divine. I learned that day never to trust the evaluation of another doctor. In practice, whenever I would be called with the consultation, I would have to trust that the doctor really did check the patient’s ears and really did examine the abdomen. And let me tell you, that every such consultation left a pit in my stomach. Until the time comes that we can totally computerize the entire physical exam of the patient and have it recorded as part of the electronic medical record, I personally will never feel comfortable with the assessment of another doctor.

To be clear and fair, I would fully understand the reverse. I would fully understand if a consultant  didn’t fully trust my assessment and wanted to see the patient on his or her own. We are trained to assess patients based on our own evaluations. And I think that’s correct.

in many of my previous blog posts, I have spoken about the ability of electronic medical records to enforce protocols, and to track every element of medical care in order to avoid, at least, easily avoidable errors. In the United States, people do not like to be labeled with a number and thus somehow feel dehumanized. My answer to this is “tough luck”. Whether it is a random number  generated by the computer, or the person’s Social Security number  or some other unique identifying value, every patient who comes to a hospital should have a wrist tag that has a barcode on it. In combination with this, every piece of equipment that is used on this patient, should have a barcode reader. It should not be possible to operate the device, whether an audit scope or an MRI machine, unless the patient’s barcode has been scanned, and the human operator verifies that the correct patient is being examined.

One of the major advances in electronic charting  is called CPOE, which basically means computerized ordering. So if you want to give the patient an Acamol, you cannot ask the nurse “please give Acamol to the patient with a headache in room 252”. Needless to say, such an order can easily be misinterpreted and the wrong patient can get the medication. Instead, with a computerized ordering system, the doctor would have to choose the specific patient intended to receive the medication, and then type out the order.

As annoying as all of this extra work may be, the results will be an Acamol pill that is accompanied by a typed order for the specific patient. And once the patient receives the medication, the nurse needs to scan the order and indicate that the medication has been given. There are actually [very expensive] medication cabinets that will only open the appropriate drawer based on the barcode or RFID of the patient being seen. If this sounds like some type of system that forces children to put their toys away in the proper place, that is exactly what it is. Doctors are very upset over such systems that drained their time unnecessarily. Any doctor who feels that such a system is, pardon the pun, overkill, is welcome to suggest  an alternate system that will reduce the insane number of medical errors that result in patients suffering and death. As of yet, no doctor has an alternate solution.

I have read countless complaints about present day EMR’s and how they dramatically interfere with a doctor’s daily work. I accept all of these complaints and I agree that they should be addressed. I would go farther and say that it is very possible that the fundamental design of every single EMR is broken. It is very possible that the fundamental assumptions that go into building a modern day EMR are so basically wrong, that it is not even possible to create a computerized tool that will be of assistance to physicians.

There is absolutely a need for a new kind of EMR that is based on a totally different set of principles. Before the iPhone, no one imagined smart phones becoming so ubiquitous and changing the lives of billions of people on this planet. Steve Jobs’ famous commercial with the final punchline being “Think Different”, did force all of the other technology companies to start from scratch and build new phones and new devices that answered the needs and desires of the public. Billions upon billions of dollars  were spent on research and development, and many of these billions ended up being wasted in poorly designed devices. But there was no other way to get to the series of phones that we have today, many of which are powerhouses with higher-quality screens then we use on our desktops. There are people who do not even have a regular desktop computer and manage entirely from their phones, with perhaps a tablet computer for certain tasks [like reviewing spreadsheets]. 10 years ago, still before the iPhone was released, none of this type of technology was even imagined. It was still all science fiction.

The time has come for someone to create the iPhone equivalent of an EMR. The time has come for someone  to wipe the board clean and to start from scratch, and to create an EMR that is so easy to use and so logical, and that makes use of the latest cutting-edge technologies to simplify doctors’ work, that we will soon forget how we ever managed without such a piece of software. Billions are spent on installations of corporate EMR’s that are considered best of the brand. And yet, the complaints about such EMR’s seem endless. It will not be sufficient to patch software that was designed for a whole different generation of healthcare workers.

Somebody has to start with a blank screen and consider where every single button will go. Such an EMR has to be visually  appealing, with a swatch of colors that are easy on the eyes even at 2 o’clock in the morning. Such an EMR should fill in as many fields automatically as possible, asking the doctor for the minimal amount of information. And when the doctor enters information that seems inconsistent with the patient, the EMR should warn the doctor about a potential error. However, once the doctor indicates that this is not an error and is appropriate for the given patient, the system should remember this and no longer bother any doctor with the same pop-up.

Of course, this is only my humble opinion and I do not expect anybody to use this blog post as a blueprint for a whole new EMR system. But that is unfortunate. The present-day needs of patients and doctors supersede the capabilities of present-day EMR’s. There is absolutely no justifiable excuse for such insanely ridiculous numbers of serious medical errors. if the legal system works properly, malpractice suits would be filed every day in almost every hospital  in the United States. Perhaps this would be the only way to incentivize the health care system to build the necessary software tools to avoid so many medical mistakes. Until then, it literally seems like a crapshoot whether your doctor will do his job properly or will slip up, but not even tell you that you almost died on the operating table due to unavoidable error. I guess that until a proper solution is found, ignorance is bliss.

Thanks for listening


About the Author
Dr. Nahum Kovalski received his bachelor's of science in computer science and his medical degree in Canada. He came to Israel in 1991 and married his wife of 22 years in 1992. He has 3 amazing children and has lived in Jerusalem since making Aliyah. Dr. Kovalski was with TEREM Emergency Medical Services for 21 years until June of 2014, and is now a private consultant on medicine and technology.
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