Repeat After Me: A Suggestion to Help Reduce Medical Errors

There’s a lot of talk today about including patients as members of the healthcare team.This is supposed to help avoid medical errors and injuries and make patient care more about the health of the patient rather than the convenience of their caregivers or the financial well-being of the institutions which care for them.

There’s a lot of talk about including patients in their own care but what about action?In my experience as both patient and observer, there’s not enough in this regard.Take the issue of medication errors.In my experience, doctors and nurses don’t take enough time to thoroughly go over details about the medications they are giving and how they should be taken. Here are just two examples – one from my own experience.

Several years ago, when I was hospitalized for appendicitis and received a laporascopic appendectomy, I got a serious complication following the surgery. Because the surgeon chose not to catheterize me during the surgery, I developed a urinary retention problem. When I left the hospital, unable to urinate properly, I had to straight catheterize myself more than 5 times a day. I also had to consult a urogynecologist. This physician decided to do a cystoscopy to see what was up – or rather why what was up wouldn’t go down. I was pretty much a wreck during all of this. I was still recovering from the surgery plus I had to deal with this awful complication.

So there I was in the room where the procedure was to be performed.  The nurse gave me a packet of pills – an antibiotic to prevent a urinary tract infection and another pill whose use I can’t remember.  I was told that I should take 100mg of antibiotics two times a day. Instead of giving me four 100mg tablets, I was instead given eight 50mg pills. The nurse went over what I was supposed to do – not just once but twice. She asked me if I understood. I said yes, I did, thinking to myself “I take one pill in the morning and one at night.” What she never asked me was exactly what I had understood.

So I went home and took one pill in the morning and one pill at night and the next morning I took another pill. And then at night I discovered that there were two pills left over. Woops, it was only then that I realized I had made a mistake and not taken enough tablets. I had misunderstood and because neither nurse nor physician had asked me what I had understood, which would have revealed the misunderstanding, I developed a urinary tract infection.

Case number two is a patient with diabetes who was given instruction in how to give himself insulin shots. Demonstrating on an orange, the nurse showed the patient how to inject himself at home. Or so she thought. The doctor taking care of the patient was surprised that the insulin was having no positive effect on the patient’s blood sugar levels. So he upped the insulin dose.  Again there was no affect. So again he upped the dose.  When this had no affect either, he decided to talk to the patient. What was he doing to take the insulin, the doctor asked?” Well,” said the patient,  “I’m doing just what the nurse showed me to do?” And what was that the doctor asked. Turns out the patient had understood that he was supposed to go home, inject an orange with insulin and then eat it.

Now you may laugh at this patient, or at me. How could we both be so dumb? Well, guess what: it’s easy. Many of us aren’t operating on all our cylinders when we are at the doctor’s or with the nurse – particularly if we are sick, vulnerable, and anxious. Sometimes, we hear the words, but they don’t register. The save button just doesn’t get pushed on our mental computers. Sometimes we totally misunderstand. Although we may be trying desperately to be good compliant, patients, we comply with what we assume to be correct, which is not. Nurses and doctors, then assume that because we are nodding our heads and saying we understand, that we actually do.

Well assumptions are always – and I mean always – dangerous. Because a lot of the time what we assume is totally false.

There’s a really simple way to deal with this. Talk to the patient. Ask the patient what they have understood. If you are a doctor or a nurse, or a PT, OT or pharmacist get them to repeat back to you what you have just told them. If the nurse who’d been using the orange to demonstrate the process of injection had just asked the patient what he was going to do when he got home, she would have quickly discovered that he’d totally misunderstood her instructions. If the nurse and doctor had asked me to repeat their instructions, I would not have gotten an infection.

It’s so very, very easy. So why does it have to be so very, very hard?