The word "Error"
The panoply of problems causing patient harm taken together are a disease afflicting medicine that are mischaracterized by the words usually used to describe them.
"Perhaps the most important step in addressing any disease is the clear delineation of the disorder. . ." according to T. Jock Murray, OC, MD in his book Multiple Sclerosis, the history of a disease.
One of the things standing in the way of making medicine less dangerous for patients is a failure to clearly delineate the range of disorders causing patient harm. The problems routinely are referred to with labels that dismiss most of what is wrong and incorrectly characterize much of the rest. Like the word Error, its synonyms, and other similarly narrow words, but I use Error as the example here because it probably is the word most commonly used when speaking about the problems that harm patients.
Description is Prescription
In his magnificent, Pulitzer Prize winning book, The Emperor of All Maladies (below right), Siddhartha Mukherjee writes that the name given to a disease either can bury it in preconceptions or wipe clean the slate to clear the field for thought. The former is what is true for the word "error" in medicine. To understand the problem, consider Mukherjee's example.
Mukherjee uses the example of leukemia, originally called "a suppuration of blood." Suppurated means spoiled, a label that simultaneously was the diagnosis: "spoiled blood." No more thought needed to be given to what the problem was. Like when food is spoiled, that is what is wrong. End of story. Move on.
Like today the word "error" is a label that simultaneously is a diagnosis. An error is just a mistake that's nobody's fault. Maybe tweak a system and move on.
A young German researcher, Rudolf Virchow, was not satisfied with "supperation." He had examined a similar case and renamed the condition "white blood," a description rather than a diagnosis. A while later he made it more academic sounding by using the Greek word for "white," leukos, and called it leukemia. That had a profound impact on the future of understanding the disease.
"A disease exists only when it is named."
- T. Jock Murray, OC, MD in Multiple Sclerosis, the history of a disease
Murray said that the clear delineation of the disorder is what makes it "so that it can be more clearly recognized, understood, researched, and managed, cured or prevented."
Words like "Error" prevent that with regard to the problems harming patients as much as "spoiled" prevented understanding leukemia. "Errors" is a wide field encompassing many different problems, but only the ones that are innocent, and probably unavoidable, accidents that unfortunately can occur no matter how attentive and well-meaning the practitioner. It does not include policies and habits that save time and money even though a certain number of patients will be harmed. It does not include incompetence, indifference, or inebriation.
It does not include the economic pressures to keep bad operators because of the business they generate. It does not include the pressure of clan loyalty to do the same. Egotism, avarice and lust are not included in the word error. Calling the disease that medicine has "errors" makes it sound as though there are no problems in medicine other than those occasional, innocent moments when everything was done correctly, but through no fault of their own, things didn't turn out so well.
A name is needed that describes all of the problems unnecessarily killing, injuring and bankrupting patients, not just the narrow range described by words like Mistakes, Accidents and Errors. The word Negligence does not cover it either. Errors are not necessarily Negligence and Negligence is not an innocent Error.
As Murray writes in the book at left, a clinician's skill is only as good as his/her ability to discern the problem. When the diagnosis is "errors" or "negligence" or "incompetence" the panoply of other problems, including the worst problems, have been excluded from thought and discussion.
Mukherjee says that "at the moment of its discovery, an illness is a fragile idea, a hothouse flower -- deeply, disproportionately influenced by names and classifications." He says that Virchow's insight concerning leukemia lay entirely in the negative, in the elimination of preconceptions. By changing the label he cleared the way for thought.
Errors as an Excuse
Daniel R. Levinson, the inspector general of HHS, says that not only do hospital employees not recognize “what constitutes patient harm,” they do not recognize when particular events have caused harm. There are so many rationalizations, so many of them used routinely, like rationalizing that a bad outcome could have been the result of some preexisting condition the patient only began to notice at the time of this treatment.
Levinson also says that when they do recognize harm they do not understand when reporting is something that they should do (for example, see Loyalty on this site).
What is an error anyway?
Just in terms of its definition the word "error" is a problem. Caregivers interpreting events of which a record needs to be made can do everything by the book, follow best practices to the letter, and still get a bad result. Is it an error? Apparently they don't think so because they almost never record them (see Medical Reporting).
Some people are more coordinated. Some are more insightful. Some younger and with better vision. Some are overwhelmed by jealousy or lust for coworkers or patients. Some are having a bad day. All of those people can do everything by the book and not get as good of a result as another caregiver would have gotten, without making anything they would define as an error, like you can lose a tennis match without making any errors just because you are not a good tennis player. So what are they to record?
They record that the treatment was perfect with no complications, that the best that could be done was done, and then persuade the patient that things would have been much worse if not for the high competence of the caregivers, even when that particular caregiver never gets a good result from that treatment.
That is a cover up
The cover up itself is not an error. And it is not negligence. It is an act of malice. It might be the most frequently committed sin in medicine since it is committed nearly every time a patient is harmed, or even could have been harmed. And it is not part of the discussion when the subject is Errors or Mistakes or Incompetence.
Patients cannot make safe decisions when there is no record of the frequency of bad results for a specific treatment by a specific provider - and that is probably the most important issue to address in order to make patients safe. Health care professionals are humans and cannot be relied upon to create impartial records. In medicine they cannot even be relied upon to understand that they themselves are not impartial. So patients must create the mechanisms to gather this information themselves. That is the core issue for patient safety, but the whole discussion uses terms that distract focus from the core issues.
Rule displayed on the tee shirt of med student: "If you didn't document it, you didn't do it."
The act of not documenting something is not an error. It is an act of volition that is malicious. It is so common and so accepted that they joke about it on tee shirts. Yet they still manage to declare and believe that they document everything. If you show them statistics on how seldom negative events are reported, they become livid and assert that everyone they know reports everything, an example of how subjective their vision is.
Their disconnect between truth and belief is lethal for patients. The patient community needs to create the means to discover the truth for themselves, or else they forever will suffer the fatalities created by health care's disconnect between truth and belief.
The term Error connotes innocence (one of the reasons health care providers cling to the term). When policies are established to save money even though they allow a certain number of patients to die and a larger number to get injured, it is difficult to label the negative outcomes as Errors. Those deaths and injuries are not mistakes or accidents. They are the predictable outcomes of policies purposely enacted.
Terms that push so much off screen
Neither "Error" nor "Mistake" nor "Incompetence" describe what happens when an angry surgeon lashes out at a patient leaving the patient disabled. There is a crime rate in medicine. When the discussion is about errors unfriendly practices are off the table.
The word "error" ignores and protects the lack of a moral conscience revealed in medicine when health care workers are unwilling to protect patients from dangerous health care professionals while, instead, working hard to protect themselves (see Cullen, or a list of similar examples).
When the enemy is within us
Pedophilia is not an error. Unnecessary surgeries done to make money are not errors. Strong-arming patients into an expensive treatments, when inexpensive ones would suffice, resulting in bankruptcy for the patients is not an error. Patients cannot be safe as long as they do not have mechanisms that enable them to learn the who, what and where of such things in spite of no one in medicine reporting them.
Everyone is Innocent
Where else on earth is this thought to be true. One perpetually hears caregivers repeat that a caregiver would have no motivation to harm a patient. That statement, in addition to being shockingly ignorant, is an indication of the breadth and depth of the self-serving myopia in medicine that shackles us with the term "error" in the first place and prevents discussion about the actual problems.
It is when we deny our role in the process that the odds of failure rise. - Nate Silver in The Signal and The Noise
The word "error" denies that caregivers have any role in most of what is harming patients unnecessarily.
"Adverse events" is a somewhat better term to use. Or "undesirable health care outcomes." Neither connotes guilt or innocence or accident. The first merely is something that is adverse. The second merely is something adverse that is medical.
Either are more inclusive terms than the word "error," but each still isn't quite right. We need a term that not only is less restrictive in what can be discussed but that also is more in line with the way caregivers discuss other problems.
The term Iatrogenic Injury would suffice, but some are starting to assume that "inadvertent" is part of the definition of Iatrogenic. Its original root confers no such conotation. Most dictionary definitions do not either, but it would be too discouraging to use Iatrogenic to replace Error only to have it taken to mean the same thing. It is probably the best option we have a the moment, but here and there it might be necessary to create a new one.
One of the problems for patients is everyone focusing on symptoms, like errors, rather than on the problems causing the errors. If we give the problems a scientific sounding name perhaps it will help to facilitate thinking about the causes of patient harm, and all of the causes, rather than thinking only about "errors."
All people are capable of being bad and rationalizing bad as being the opposite. We need a term that allows room for including that in the discussion. Not everyone and everything in medicine is innocent. "Errors" are innocent. The worst problems harming patients are not.
The many small acts of volition committed by providers that result in a cumulative damage to patients that is enormous are part of the problem, and they are not errors. There also are enormous acts of volition by individuals at specific moments that ruin lives. Neither are accidents. Neither are innocent. Neither fit under the rubric "error."
The naming and classification of disease
Medicine is afflicted with an inflammation of people and practices and institutions that harm patients. "Iatrogenesis" sounds like a systems problem. "Adverse event" is a label likely to limit the discussion to moments when something did not go right, instead of including acknowledgement of things like conflicts of interest creating policies that cause deaths.
We need a word that describes a pervasive illness, a disease, affecting the entire body of the medical establishment in many ways. Perhaps someone knows a better one, but I am starting to use Nequamitis, a word that is similar to the labels commonly given to diseases.
The language used in medicine often makes knowledge of it seem to be beyond what mere mortals can understand, and it includes a lot of Latin and Greek, as does the word Nequamitis.
Nequam is Latin for worthless, good for nothing, or bad. "Itis" is a suffix derived from Greek meaning inflammation. When a caregiver or a treatment causes injury to a patient, at the very least that caregiver or treatment was not good for that patient. When the entire field maintains practices that injure patients but benefit itself, it is inflamed with an affliction that can be referred to with a word like Nequamitis. What it cannot be referred to as is "errors."
Greek carries legitimacy in medicine. The Greeks introduced to medicine the idea of learning by observing experience. Until then they relied on prayer to heal and chalked failure up to God's will rather than learning from it. The invention of the printing press helped spread to medicine in Europe the new Greek method of learning from experience when an Italian printed Hippocrates, Aristotle, Dioscorides, and other Greek authors in their original languages. Great strides were made in medicine because of ideas learned from the Greeks. This created a culture that had the sense that things from the Greeks were legitimate and worth paying attention to.
Culture is strong and enduring. Things Greek still carry weight. This is why so many diseases have names derived from Greek and Latin roots. There are words in common parlance that originally were created in this way in order to describe diseases, like the word Nostalgia which was coined in a paper by a medical student trying more accurately to describe a problem for mercenaries in a distant land. The word was created from two Greek words.
It behooves us to give the illness afflicting medicine a name that fits in with the way the culture in medicine works. The problems afflicting medicine need a name that is both accurate and feels legitimate to people in medicine.
Once in a while a speech or an article or a file folder should be labeled Nequamitis for the accuracy of its breadth. Labeling them Errors when the subject is the problems harming patients is no more accurate than using the label Gnats or Mosquitoes when the subject is the problems harming people walking through a mine field. You can die from either an error or a Mosquito bite, but they are equally misleading delineations of what the problems are and what the discussion needs to be about if the goal is to save lives. They are, in fact, misdiagnoses.
Misdiagnosis or delayed diagnosis is thought to be the greatest source of patient harm. This is not new. Consider the problems killing chimney sweeps in the 1770s in England. About that Mukherjee writes that when children working as chimney sweeps presented the sores on their private parts that were characteristic for members of their profession, they easily were dismissed as the just desserts for the licentious lifestyle of coarse people. They were treated for venereal disease. When that didn't cure it, they were treated for it again. And again. Good business for caregivers, but bad for patients to be repeatedly exposed to toxic substances that do not cure them.
The children who were getting cancer were getting it from exposure to soot that was difficult to clean completely from the wrinkled skin of their private parts back before homes had running water and showers. They were, after all, only children, some as young as 4 or 5.
A careful and concerned researcher pushed aside the preconceptions (Venereal disease in a 4-year-old? How licentious can a 4-year-old be?) and became the first person in history to consider the idea that exposure to a substance like soot might cause a disease. Medicine was changed forever by his having this insight when his thinking was not constrained by the preconceptions presented to him by the rest of his profession.
Today the medical profession's preconceptions include the notion that medicine is full of good people who once in a while might happen to be present when an error is caused by the system through no fault of their own. One hears them say that they don't think it is that much of a problem. They say voluntary reporting would uncover it if it were. The word "error" defines the problem in a way that enables them to believe such things in spite of all the evidence to the contrary.
We should ban the word "error" forever from patient safety discussions and use words that allow thought to roam away from medicine's self-protecting preconceptions and into realms about which they are in denial. Otherwise, patients are letting caregivers set the terms of the discussion in ways that protect caregivers and hurt patients.
It is not just verbiage. It is the scope of what we are able to think. How the problem is framed determines what can be understood about it and how the problems might be eradicated or modified.
Whatever the name for the broad scope of the field might be, next we need to create divisions under it so that we might identify and solve the narrow divisions within it.
What would be the correct label for the dangers for patients caused by caregivers believing self-serving lies, rather than the evidence that contradicts it? What would be the term for dishonest causal reporting, or for reports that cover up misdiagnoses leaving illnesses untreated in order to avoid drawing the attention to the misdiagnoses? What would be the correct term for it when they believe a lie because the caregivers around them believe the lie (see the findings of psychologist Solomon Asch on a page on this site). What would be the correct term for having no idea that their thinking is pre-Greek because is not based on any appraisal of evidence?
People routinely dismiss problems based on preconceptions they have picked up from others. Medicine is no different. Removing excuses to do that is important.
For instance, AIDS originally was called, GRID, for Gay Related Immune Disease. It was easy to dismiss when called GRID. GRID was what the patient deserved for gay related excess.
An epic shift in the understanding of that disease came about when its name was changed to AIDS for Acquired Immuno Deficiency Syndrome.
"Errors" too are easily dismissed, and too easily not regarded as worth reporting, since they are no one's fault and no system is perfect, etc. The word "error" does not even include the worst problems for patients. We should be talking about the worst problems as well as the smallest ones, don't you think? The victims sure do.
Let's wipe clean the slate for thought and abandon the word "error" and its comforting (in medicine) preconceptions. If we are not going to use the word Nequamitis, let us at least stop defeating thought and discussion by pretending the problem is nothing but some mistakes or "errors."