The James Logan Courier

By Howard Cohen
McClatchy Newspapers (MCT)

MIAMI — The patient's on the operating room table. His upper body is punctured with stab wounds. He's kept alive via snaking tubes infiltrating the gashes.

The lights go out. Power failure. The ventilator, inoperable. The doctors, nurses and anesthesiologists are in the dark; a senior surgeon barks orders.

Thankfully, the victim is a "model patient." A mannequin.

This is the University of Miami /Jackson Memorial Hospital Center for Patient Safety, a program Dr. David Birnbach and his crew employ to teach medical students, residents, interns and health care staff how to react to emergencies, communicate more effectively and most importantly, reduce medical errors, a critical area in the medical profession that can lead to costly mistakes, medical malpractice suits and patient deaths.

Launched on a $950,000 state grant three years ago, the center offers a series of mandatory courses like the in-the-dark operating room scenario. Instructors simulate real-life situations _ say, a mother showing up in the emergency room with a breached baby halfway through the birth canal and too late for a C-section — using medical equipment, mannequins, and the occasional actor to play a patient or harried orderly.

One of the key goals? Communication, says Birnbach, the program's director and the school's vice chair in the Department of Anesthesiology. It begins from the early days of medical school.

"We are teaching doctors how to talk to doctors, doctors how to talk nurses, and we start right from the beginning. In their second year, they can't start working on patients in a clinical scenario until they have 16 hours of lectures on communications," Birnbach says. "You "are" going to make mistakes. What are you going to do then? What systems are going to help you? How are you going to remedy this and make sure you never make this mistake again? That's what they get lectured on and then they come to the simulator."

Once a staple of the TV sitcom, the medical mistake — operating on the wrong body part, prescribing the wrong medication — is a high-profile issue in the real world.

A recent case centered on a 3-year-old Gainesville, Fla., boy who was accidentally given a dose of a drug 10 times greater than the doctor's prescribed amount. The child, Sebastian Ferrero, died Oct. 10 at a Shands HealthCare facility at the University of Florida. The error occurred even though the boy's mother questioned the dose as it was being administered.

Medical errors impact 1.5 million Americans each year, according to a 2006 Institute of Medicine study. That most recent report from the Washington-based research group also attached a bill for these errors — $3.5 billion, assuming a conservative estimate of 400,000 of these events, which can include mistakes in procuring, prescribing and dispensing drugs. A serious drug error can add more than $5,800 to the hospital bill for a single patient — and can lead to death.

A landmark study by the same group in 1999, "To Err Is Human," said that 44,000 to 98,000 people die in hospitals each year from medical errors. The group could not forecast a number for the 2006 study.

"It's very serious, that's why the commission did the study," says Linda Cronenwett, who co-chaired the Committee for Identifying Medical Errors for the Institute.

"The average patient in a hospital has about one medical error every day, which is a figure that resonates with people," says David Bates, a Harvard Medical School professor who was on the Institute of Medicine's investigation committee. "Fortunately, most of these errors have little or no potential harm but with children, in particular, tenfold errors — giving 10 times a dose — are common because children come in such different sizes. Those errors can be especially risky."

The Institute of Medicine has called for a nationwide switch to electronic prescriptions rather than handwritten, error-prone prescriptions, and set a date of 2010 for all pharmacies to use e-prescriptions. "We're probably not going to get there as a country but we did call for that date and it's not unrealistic," Bates said.

Already, many South Florida hospitals are on board or are converting to e-prescriptions, among them Miami Children's Hospital, Baptist Health South Florida, University of Miami/Jackson and the Memorial Healthcare System in Broward County. In September, Memorial launched its LifeWings program, an aviation industry-based series of steps designed to train personnel on safety practices and teamwork.

Florida is also one of 30 states to have adopted the so-called "I'm sorry" laws, which can render comments that physicians make to patients after an error inadmissible as evidence for proving liability.

"The UM-JMH Center for Patient Safety has actually begun teaching physicians how to honestly disclose errors to patients by having them practice with simulated patients while they are videotaped," Birnbach says.

At the UM Center this day, students are treating a "model patient" suffering from angina.

One student gives the "patient" too much of a drug dosage because she wasn't clear how much another doctor had previously given the patient. The heart rate soars; "she" becomes unresponsive.

The students are filmed on disc and migrate to a nearby classroom for evaluation.

"I should have lowered the bed's rails so I have more access," says the student, watching herself on a screen.

"I should have recognized the unstable rhythm. I was totally fixated on the one thing," the student continues, eyes darting from screen to simulation anesthesiologist instructor Daniel Castillo.

"In a crisis situation you bring all your team together," instructs Castillo. "We tend to focus and tunnel vision things. You'd still be thinking of the same thing if the patient flatlined. There were some doctors next to you, you could have called to them."

"I feel like I could have handled it much better," the student nodded.

Programs like this are important, the Pennsylvania-based Institute for Safe Medication Practices says, because they promote openness and clarify procedures.

"There's an old adage in teaching medicine: `See one. Do one. Teach one.' And that's a failed model of education," adds Dr. Joshua Lenchus, the associate program director and assistant professor of clinical medicine at UM. "This is a much more structured and uniform way of doing it. ... Once this is completed, we go to the hospital under supervision."

But sometimes real cases at the hospital prove impossible to practice upon. Take the partially delivered breached baby situation. "We can't teach people to do that on the labor floor ... so when would they learn this if not in a simulated environment?" Birnbach says.

In a nearby room, two chief residents are practicing the removal of the baby under the supervision of OB/GYN Salih Yasin.

"I feel pretty confident," resident Gregory Guell says, "I think this program trained us well for this."

HELP MINIMIZE ERRORS
A few things you can do to help minimize medical errors: :
—Maintain a list of all drugs you are taking, both prescription and over-the-counter. Include vitamins and supplements. Have your doctor go over the list.
—Make sure the name of the drug and the directions printed on the bottle you receive at the pharmacy match the prescription.
—Ask your pharmacist for specific directions on how to take the drug and whether you should expect any side effects.
—Ask your doctor or nurse to tell you which drugs you are being given — and why.
—Exercise your right to have someone you trust present when you are receiving medication and are unable to monitor its intake.
—Before surgery, ask whether there are any meds you should be taking — or should stop taking — preoperatively. If undergoing surgery, ask whether the hospital has error-prevention procedures to help minimize surgical errors. For instance, if your left foot needs surgery make sure someone marks that foot before you go under.
—Before discharge, request a list of the meds you will be taking home and go over them with your doctor. If in doubt about how to take them, speak up.
— HOWARD COHEN

SOURCE: Committee on Identifying and Preventing Medication Errors, Institute of Medicine.

(c) 2007, The Miami Herald.
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