Perspective: Bob Newhart (“Stop it!”) vs. CRICO (“Big data”): Which can best reduce medical error?

By Charles A. Pilcher MD FACEP
July, 2016

One of my all-time favorite skits is the scene from the Bob Newhart Show in which he plays a psychiatrist whose advice to a patient with a “fear of being buried alive in a box” is to just “Stop it!”

Seems simple enough, right?

The counterpoint to such advice is to psychoanalyze the situation to death to identify all possible esoteric foundations for such a phobia, then propose a variety of exercises to reduce and hopefully terminate it.

Unfortunately, when dealing with medical malpractice, the latter seems to be the only accepted approach [See example below / CP]. No one is telling physicians what is really happening and then showing them how to simply “Stop it!” I believe we can improve patient safety much more quickly and efficiently and reduce medical errors – maybe even eliminate them – if we just “Stop it!”

But how?

The problem

The problem is that physicians – the ones who have yet to make a medical error resulting in a malpractice lawsuit – do not know what mistakes are being made. What is happening to their colleagues? What errors are most common? Which ones are most likely to get them sued?

Why don’t they know? Because no one tells them – at least not in a way that hits home. No one ever just tells them to “Stop it!”

The CRICO/RMF Strategies Project:

An example of excessive “psychoanalysis of medical error,” i.e., “big data,” is a project done 6 years ago by CRICO/RMF Strategies, a large, Harvard-based med mal insurer and data aggregator. [Editor’s note: CRICO claims (in classic Ivy League language) to be able to “dramatically reduce medical errors and minimize financial loss through proven methodologies and data-driven insights that reveal hidden areas of risk and deliver actionable intelligence to drive fundamental change that transforms the safety of patient care.”]

Really?!

As part of that grandiose hyperbolic mission they convened a group of 40 emergency medicine leaders in 2010 to address medical error in the ED, the number one cause of which was found to be diagnostic error. The goal of the project was to identify specific causes and pilot solutions to the “crisis.”

Based on the project’s analysis of CRICO’s repository of “big data,” they found [not surprisingly/CP] that breakdowns in communication led to the greatest rate of diagnostic error. Specifically, “some element of missing information and/or gaps in communication among physicians and nurses were involved in nearly 80% of the cases…[P]hysicians were often missing essential pieces of information at the time of decision making, which led to misdiagnosis.”

The gaps in communications identified were:

  • Missing prior historical information
  • Changes in patient status and/or vital signs
  • Delays in lab and imaging data,
  • Communications with consultants,
  • Handoffs,
  • Nurse/physician communications

Suggestions to improve nurse/physician communications included:

  • Structured communication events or “huddles”
  • Operational and organizational change to standardize processes to eliminate errors and eliminate non-value-added work (LEAN principles)
  • Staff development and education through the use of simulations

The involved hospitals then field-tested “one or more” of these suggestions. In summarizing the CRICO/RMF Strategies report, CRICO’s Dr. Robert Hanscom said, “The result is a set of real-world practices designed specifically to enhance patient safety and minimize risk in the ED setting.”

But has it worked? Did communication improve? Did patient safety improve? Have med mal cases decreased?

Well, apparently no one has bothered to find out, based on a search of the literature. One would think that someone at sometime within the past 5 years would have been curious enough to find out if this “big data psychoanalysis” worked.

In fact, according to Diedrich Health Care, in the past 5 years the overall cost of med mal settlements has climbed significantly, totaling nearly $4 billion in the year 2015 alone. The year 2011 was actually the nadir. And the rate of diagnostic error in the claims analysis is unchanged at about 1/3 of claims settled. Whether the hospitals in CRICO’s study were any different is unknown – or at least not published.

Big Data? Or simply “Stop it!”

Yes, an element of medical malpractice involves communications. However, cognitive errors continue to predominate. Thus, teaching physicians how to think better is at least as important as teaching them how to communicate better.

To teach them to “think better,” sharing actual case settlements with physicians and other healthcare providers is proving to be a far simpler, cheaper and more effective way to improve patient care, make it safer and reduce error. When practicing physicians are presented with actual med mal settlements in which patients have been harmed by other physicians’ medical errors – and shown how those errors were made – they change their practice. They think better, document better and yes, communicate better – both with their patients and their co-workers. [Based on reader feedback on Medical Malpractice Insights – Learning from Lawsuits. / CP]

If we have a phobia, we can spend years in psychoanalysis. If we’re spending too much on medical malpractice, we can study big data looking for answers.

Or, we can simply learn from someone who’s been there, then listen to them when they tell us to “Stop it!”

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