An interesting thing happened after I presented the first case. They were interested. It seems cutting off the wrong leg resonates with high school students. Moreover they were aghast that these types of medical errors were occurring. They were shocked that such smart people could make such dumb mistakes. Mr. Narcolepsy slid out of stage 1 sleep long enough to sarcastically note that even he knew that heart attack patients should get aspirin.
I asked them how they thought we could avoid these mistakes. A girl in the front wondered if we couldn’t just ask the patient which leg they wanted cut off. I noted that patients are anesthetized when we meet them for the surgery. She then proffered that perhaps we could ask them while they were awake and then mark the correct leg with a marker prior to going into the operating room.
Regarding the ICU transfer patient who had a medication drop off her med list, a quiet kid in the front asked, “Why don’t you just compare the list of medications used in the ICU to those outside of the ICU?” Another suggested that the two different teams of doctors could sit down and discuss the patient’s medications to be sure nothing was left off.
They wondered if we could avoid forgetting important medications—such as was done with the aspirin for the MI patient—by making a list of the things every patient with a heart attack would need. For example, didn’t they need an EKG, some lab tests, and some medications? Wouldn’t it be best to just have this list so that we didn’t have to remember all these things?
Unwittingly, these teen-agers—none old enough to shave—had just in their own words recited some of the key tenets of the patient safety movement:
- Active communication with the patient prior to surgery;
- Time out prior to surgery to ensure correct patient and surgery;
- Marking the site of surgery;
- Improved communication around patient handoffs;
- Medication reconciliation at every transfer of care; and
- Use of protocols to ensure best practices.
I was floored. In 30 minutes, a group of teenagers had developed a list of hospital safety measures that it has taken modern medicine generations to grasp.
The amount of medical errors has risen in step with the complexity of the medical care we provide. However, this does not mean that the causes of these medical errors are complex. Rather, most errors result from simple mistakes and systems issues. In fact, as I was taught on that fateful spring morning, I learned everything I need to know about patient safety in high school. TH
Dr. Glasheen is associate professor of medicine at the University of Colorado, Denver, where he serves as director of the Hospital Medicine Program and the Hospitalist Training Program, and as associate program director of the Internal Medicine Residency Program.