Have you heard of Captain William Hamman? If not, let me recap. He’s the modern day version of Frank Abagnale Jr. for whom the 2002 movie ‘Catch Me if You Can’ was about. Captain Hamman has duped the American Medical Association, a university, hospitals and most of his colleagues for the past 15 yrs by posing as a cardiologist when he actually never graduated from medical school, much less a residency or fellowship program. He has spent the last 10 years teaching other doctors about the importance of team work in treating patients, and the value of instituting a check-list mentality to help reduce medical errors. Thankfully, no patients were ever treated or at risk of being harmed by him.
So what’s to learn from Captain Hamman besides always performing a background check before you hire a new doctor or award him a grant for millions of dollars? His case brings to light the importance of reducing medical errors. The IOM release a report called ‘To Err is Human: Building a Safer Health System’ in 1999. It stated that at least 44,000 and possibly up to 98,000 Americans die each year due to a medical error. A medical error is defined as ‘the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim’. Besides the great human cost, medical errors cost our system up to $29 billion per year. Much of this through additional treatments, re-admissions and liability issues related to these errors.
10 years later things have not changed much. Two recent studies reveal that while some changes have been made we still have numerous adverse events occurring due to medical errors. The Office of Inspector General released a report in November 2010 called ‘ADVERSE EVENTS IN HOSPITALS: NATIONAL INCIDENCE AMONG MEDICARE BENEFICIARIES’. They randomly sampled 780 Medicare beneficiaries and found that 1.5 percent of them experienced an event that contributed to their deaths, which projects to 15,000 patients in a single month.
The New England Journal of Medicine released a follow up analysis of the 1999 Institute of Medicine report that reviewed 2341 cases from admissions at 10 NC hospitals & found ‘that harms remain common, with little evidence of widespread improvement’.
So is there any good news? That same New England Journal of Medicine article did find that certain interventions have made an impact in reducing medical errors like: implementing computerized order-entry systems, limiting residents' work shifts to 16 consecutive hours, and implementing evidence-based care bundles.
The best news is that CMS is now headed by Dr. Don Berwick. Dr. Berwick has become synonymous with reducing medical errors. He co-founded the Institute for Healthcare Improvement (IHI) (www.ihi.org) in 1991 whose aim is to create a health care system in which we provide safe, effective, patient-centered health care. There is an inherent realization that by doing so, we will be able to provide quality care while bending the cost curve. The IHI offers programs directly addressing surgical site infections, medication errors, decreasing emergency department visits for asthmatics, etc.
We are lucky to have a pioneer in patient safety leading CMS; especially a man who clearly sees the link between reducing medical cost and reducing medical errors.
So while I feel badly that Captain Hamman has made a fool of himself and so many others, his desire to help reduce medical errors is valiant. When his ruse was revealed he asked the American Medical Association to allow him to continue his seminar he was quoted as saying ‘the work is the work’. Agreed, but I’d rather let Dr. Berwick lead us.