21 March 2016

Observations About Medical Mistakes

Vox has a nice article on medical mistakes that cause harm.

Medical mistakes involve a nest of probabilities that have to be well understood to made good judgments about what to do about them.

1.  Most people who are experiencing medical conditions that put them at high risk of bad outcomes seek medical attention.

2.  The outcomes of people who are at high risk of bad outcomes who seek medical attention on average are much better than the outcomes of those who don't.  The sweet spot of people at high risk of bad outcomes who are better off not seeking medical attention has grown smaller and smaller.

3.  There is a great deal of overlap between the people most qualified to provide medical attention and the people who actually do provide medical attention.

4.  Almost all medical providers make medical mistakes that cause harm at some point during their careers and frequently, they do so repeatedly.

5.  The more often and more seriously a medical provider makes a medical mistake, the more likely that medical provider is to do so in the future.

6.  The vast majority of medical providers who make medical mistakes provide benefits from their medical treatment that exceed the harm that comes from their medical mistakes over the course of their careers.

7.  The rate of medical mistakes per provider is much more a function of the quality of the systems in the organization where the person provides medical care than it is a function of the quality of the mind or education of the provider.

8.  The article focuses on the fact that medical providers not only don't want to make medical mistakes that cause harm, but also feel very bad about it when it happens to the point that they suffer mental health consequences.

9.  A medical provider who has spent most of a career making few and minor medical mistakes can be at much greater risk of making major medical mistakes when impaired for some reason.

10. Fear of liability discourages organizations that provide medical care from identifying all medical mistakes when they happen and devising means of making them happen less often, even though this means that the total number of medical mistakes may be higher.  This is rational in many cases for the provider since it may minimize the number of medical mistakes giving rise to claims even though it doesn't minimize the number of medical mistakes.

11. Subtle errors in medical treatment that are easy to make in the absence of exemplary systems to prevent them, and hard for anyone but the person making them and their close associates, can still have grave consequences.  For example, transposing a number, misplacing a decimal point, or confusing two very similar looking bottles can result in a drug administration error with deadly consequences.

12. Unless a medical mistake is extremely obvious, it is unlikely to have consequences legally unless the outcome is very bad.  Yet, when the outcome is very bad, litigation is likely even when no medical mistakes were made.  And, a large share of the funds spend on the system for compensating victims of medical mistakes go to transaction costs.  But, few non-meritorious medical malpractice suits prevail in litigation and result in large dollar awards to victims of medical malpractice.

13. We want to compensate victims of medical mistakes appropriately.  And, we don't want to spent too much time and effort on transaction costs relative to compensation, if possible.

14. We don't want medical providers who aren't excessively likely to make medical mistakes to continue to provide medical services because they do more good than harm and the alternative of replacing them is worse.

15. We want a system in which mistakes are identified in a manner that causes organizations providing medical services to improve their systems to prevent them from happening in the future. This can only happen if the culture of medical professions is changed and the cultural change does not lead to net negative outcomes for the organizations that change their culture.

16. We want people to trust medical systems that on average make them better off even when medical treatment isn't zero risk.

17. Medical malpractice awards require proof of negligent conduct by a medical provider that causes harm.  But, proof of causation is difficult because even non-negligent conduct can lead to bad outcomes when someone has a medical conditions that requires treatment.  And, medical providers tend to think of negligence in terms of mistakes that a reasonable medical provider would never make in any entire career, while the law thinks of negligence in terms of something that a reasonable medical provider clearly wouldn't do if one was paying attention and mindful at that very moment. Also, unlike most litigants, medical providers, due to the long term reputational harms associated with settling a medical malpractice case are unlikely to settle in cases where they believe that they did not make a mistake. Thus, in this kind of litigation in particular, the least culpable providers are often the most likely to take a case to trial and even if they lose may be less culpable than those who settle promptly.

18. There are institutional barriers to proving medical malpractice because medical providers who testify as experts against other medical providers tend to be ostracized by their colleagues in all but the most obvious cases.

19. Medical technology is not so advanced that all treatments reliably work all of the time when used properly.  Many forms of medical treatment and diagnosis have error rates that cannot be eliminated with any amount of care using current technologies.  But, as medical technologies improve, a larger share of bad outcomes are due to medical mistakes and are preventable with exemplary care.

20. The threshold of care quality at which it is better to provide medical care than not to provide medical care is much lower than the state of the art medical care quality.

21. Some steps to prevent medical mistakes are cheap and easy, but are not implemented systematically.

22. Some steps to prevent medical mistakes are expensive and difficult, even to the point where the cost does not usually justify the precautions.  The best can be the enemy of the good.

23. It is often difficult to estimate the quality of an organization that provides medical care because organizations that do a better than average job in dire cases may still have higher rates of bad outcomes than organizations that do a below average job in dire cases but have fewer such cases.

24. For a patient, the experience of a bad outcome that is unavoidable even with mistake-free medical care is often virtually indistinguishable from a bad outcome that is caused by a medical mistake.

25. Bad outcomes often trigger grief on the part of both the patient, the patient's loved ones, and the medical provider, even when no medical mistake has been made and grief can lead to irrational or counterproductive action.

It is hard to devise a system for addressing medical mistakes that has the right incentives and produces the best possible outcome given this complex set of realities.

For example, one of the most common knee jerk tort reforms is to cap compensation for medical malpractice awards, even though, by definition, this reduces recovery from the people who actually are victims of medical mistake determined to the highest level of precision feasible in our system who suffer the most harm, rather than reducing transaction costs or costs associated with suits where there was a bad outcome but not medical mistake made.

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