Nov 9, 2009

A Grey’s Take on To Err is Human

Hi, my name is Eva and I watch Grey’s Anatomy.

I started about three years ago with the hotly anticipated Season 2 Finale and have been addicted ever since. I have tried to stop and had hoped that a change in environment (back in school and no TV) would stop this unhealthy habit. But, I have been unsuccessful. In fact, I believe I have reached a new level of addiction.

At the end of every episode I watch, I have been able to extract a lesson to justify my time spent following the lives of the characters at Seattle Grace Hospital. I tell myself that these lessons learned will help me become a better doctor…

For example, episode 6 of Season 6 ("I Saw What I Saw"), in my eyes, is a clear case study on patient safety and systems thinking. Let me explain.

    The system at Seattle Grace Hospital: The economy has shaken the foundations of Seattle Grace Hospital. Like leaders of hospitals around the country, the Chief of Surgery has had to make some tough decisions. A solution to some of the financial problems was a merger between Seattle Grace and Mercy West, a neighboring hospital. This led to staff cut-backs and an influx of new colleagues from Mercy West. The Mercy West additions were given no formal training to the ways of Seattle Grace. Caring for patients should be the same no matter where you are, right? Compounding this situation is the distrust and tension between the staff at Seattle Grace and the staff from Mercy West because they all anticipate more layoffs.

    "Survival of the fittest" is everyone’s mentality. Everyone seeks to capitalize on the other’s weaknesses. In emergency situations, patients needing care are wheeled in and taken care of on a first come first serve basis. Patients are viewed as opportunities to shine. Everyone envies the surgical resident asked to assist on a patient with tough and difficult injuries. No one takes responsibility for the patients who don’t have “cool” conditions. The episode takes place just shortly after the merger of the two hospitals.

    The case: Mrs. Becker and her son were just two of an influx of patients involved in a large fire at a hotel. Mrs. Becker presented with minor burns and her son appeared unscathed. Both Mrs. Becker and her son were very scared. After an initial hurried physical exam, Mrs. Becker and her son were left alone. She received treatment for her 2nd degree burns and morphine for her pain. By the end of the night, she suffered a pneumothorax (a collapsed lung) that was emergently treated with a cricothyrotomy, and then passed away due to respiratory distress followed by multiorgan failure. A disjointed “team” of seven residents (some of whose names many are still unfamiliar with) had attended to Mrs. Becker through the night.

The episode, filmed in the Rashomon style, retells the night from several vantage points to simulate the Chief of Surgery’s investigation on the death of Mrs. Becker. At the end of the interrogation, it was discovered that Dr. April Kepner had not completed Mrs. Becker's initial physical exam thoroughly. She missed the soot that had accumulated in Mrs. Becker's airway and lungs. The soot was the cause of Mrs. Becker's organ failure.

    Leadership actions taken: Dr. April Kepner was fired for her negligence.

We are very quickly approaching the 10th anniversary of the Institute of Medicine’s (IOM) landmark patient safety report, To Err is Human: Building a Safer Health System. One of the most important messages of the report was that systems failures cause most injuries, not bad clinicians. Judging by the Chief's decision to fire Dr. April Kepner, he clearly has not read the report. Dr. Kepner was not a flawed or bad doctor, she was simply forced to operate in a bad system: She was not taught how to navigate the new hospital. She received no support from her colleagues. The process of admitting patients was chaotic and disorganized. Dr. Kepner and Mrs. Becker had no privacy. And communication between all of the physicians present was abysmal. Is it a surprise that Dr. Kepner would make such a simple mistake? I think it's a bigger surprise that more catastrophic mistakes didn't happen that day. Firing Dr. Kepner would not prevent a death like Mrs. Becker's death from happening again.

Dr. Shepherd has probably read To Err is Human. He understands that every system is designed to achieve the results that it gets. To prevent harm to patients, the Seattle Grace team needs to reduce the chaos and improve their work processes in order to fix the system. A point for those who swoon over Dr. McDreamy!

To have patient safety and systems thinking be major themes to an episode of a popular television show should be a good sign of progress in the field of quality improvement and patient safety, right?

Today's health care reform environment has thankfully showcased some of the many activities taking place at hospitals and professional societies to improve health care. Signs that quality improvement and patient safety are on the national radar have been allocation of funds in the Recovery Act towards comparative effectiveness research and reduction of hospital acquired infections. How to improve the quality of health care delivery while reducing costs has also reached the national scene (addressing overuse and underuse of health care). At a more local level, actions are being taken to reduce hospital acquired infections, reduce medication errors, and standardize safer and best practices (addressing misuse of health care). New accreditation standards and regulations such as no payment for "never events" adopted by the Centers for Medicare and Medicaid Services can also be taken as a sign of progress.

But, do I feel safer or sense the improvements made whenever I interact with the health care system? As this episode of Grey's Anatomy demonstrates, tangible and measurable progress is probably still not yet within our grasp.

Once we get there, this episode should be rewritten. Seattle Grace will be a shining example of the transformation of the culture of medicine. All of the characters would not be individual heroes searching for glory, but would support each other in order to deliver better care for their patients. The Chief and hospital leadership would not bury mistakes like Mrs. Becker's death, but would take the time to identify root causes of the error and fix the system. And every single person would critically evaluate and make improvements to the complex work processes of delivering health care.

The best indicator of progress in "Grey's speak" would be a scene where Dr. Cristina Yang pouts because she was not named as the resident who discovered and made the greatest number of improvements in the Department of Surgery, rather than the fits we see her in now whenever she is not named the most technically accomplished surgical resident.

I should probably take a few seconds to look up the medical term for severe addiction now...