My gamma always told me you shouldn’t say the word devil too many times. She was afraid it could attract the Prince of Darkness. Of course I never believe in it. However, I do not dare saying the word Beetlejuice three times. I think it’s easier to pretend something don’t exist if you don’t talk about it. Today, we’re unafraid, and we’re going to discuss an uncomfortable subject: Iatrogenisis (from the Greek for “shit! shit! shit!”).
Newton once said: An object at rest stays at rest unless acted upon by an unbalanced force. No, sorry, that quote was from a post about anesthetists I’m writing. The right on is this one: For every action, there is an equal and opposite reaction. Although some might say Newton was talking about physics, the truth is he was talking about that time you prescribed that unnecessary heparin and Mr Mustard bled to death, or maybe that time when Mrs Robinson discovered how to breath under water thanks the fluid you gave her (Hi Five Surviving Sepsis!). Ok, we know how complex medicine really is, and that not every iatrogenic disease is due to predictable human error, but unfortunately, shit happens, and the are so many intangibles. It’s not like flying an airplane, or just following the checklists. Patients do not have manuals, and unless you give them some ketamine, they also do not fly. The real problem became that sometimes small, sometimes huge preventable part. The one we are used to ignore, it’s forbidden to talk about it. It’s our Beetlejuice.
Since we are thought to hide our mistakes (remember when you broke your aunt’s dished and said it was the dog?), I’m not surprised how hard is to find publication regarding this theme. But here are some: An Israeli observation study found that an ordinary ICU patient is exposed to 1,7 medical erros/day, with 29% of them being potentially fatal. In a 6 month observational study, Mercier found that 20% of ICU admissions were somehow due to iatrogenic events, half of them related to medications errors and 74% preventable! If you are astonished, wait until you see the data about low/middle income countries.
In an Indian Nursery, 33% of patients suffered medication errors during their hospital stay. Of the mistakes imputed to nurses, most of them were due to: lack of training, excessive labour hours, and stressful environment. Regarding the physician’s errors (55% of total errors) were due to unclear orders. U-N-C-L-E-A-R orders! Really?Have you ever heard of closed loop communication?
We all know the butterfly effect. An old guy cannot sleep, someone prescribes some benzos, delirium kicks in, some haloperidol comes up, level of consciousness compromised, orotracheal tube comes in, blood pressure goes down, norepinephrine right now, atrial fibrillation speeds up, amiodarone pumps in, QT interval goes long, and some day the patient dies from natural causes. he was old, and that what old people usually do. They die. That’s why Peter Pan didn’t want to grow up. he was afraid to end up in an ICU.
Have you ever thought about how many times you did something like this? How many times your actions somehow might have influenced the undesired outcome? Of course the real life poetry is far more fluent and the hall of actors are more convincing than my writings. These are tough questions. We dedicate our lives to help patients get better (whatever this may be). We are comfortable with the idea we may harm them sometimes. The One Million Dollar question is: are we doing something to prevent this from happening? We’re probably going to see the apogee of the Doing Less era, and I really think the answer lies in this mantra. Less unnecessary antibiotics, less unnecessary procedures, less unnecessary diagnosis and therefore less unnecessary treatments, less fluids. Let’s treat the patient, not the disease. This should be out mantra.
Beetlejuice! Beetlejuice! Beetlejuice!
1. Donchin Y, Gopher D, Olin M, et al. A look into the nature and causes of human errors in the intensive care unit. Crit Care Med 1995;23:294-300
2. Mercier, E., Giraudeau, B., Giniès, G. et al. Iatrogenic events contributing to ICU admission: a prospective study Intensive Care Med (2010)
3. Karna k, Sharma s, Inamdar s, Bhandari a. Study and evaluation of medication errors in a tertiary care teaching hospital – a baseline study. Int j pharm pharm sci, vol 4, suppl 5, 587-593