Gaps in Care: The Hidden Cost of Complexity and Overload

Errors and gaps in care have become inevitable consequences of the complexity of today’s medicine and the overload of today’s physicians. When these gaps aren’t identified and closed, opportunities are missed

In 1999, a landmark report was published by the Institute of Medicine titled “To Err is Human: Building a Safer Health System.” The report, based upon two major studies, made a sobering statement about healthcare in America: “At least 44,000 people, and perhaps as many as 98,000 people, die in hospitals each year as a result of medical errors that could have been prevented.”1 The report was a bombshell in the medical community at the time, but what’s even more astounding is that the statistics have only gotten worse—much worse.

Research published in the September 2013 issue of the Journal of Patient Safety estimated that up to 440,000 Americans die annually from preventable hospital errors, making them the third-leading cause of death in the United States.2 And as shocking as these numbers are, we know that not every medical error results in death. Tens of thousands of errors or gaps in care lead to misdiagnosis, missed interventions, preventable infections, incorrect prescriptions, or even the wrong surgery.

Many of these can be corrected (or at least survived). In the meantime, however, they certainly have an impact on patients—and doctors. After all, most of us went into medicine to help people. So what can we do to reduce the likelihood of errors and gaps in care that impact outcomes for our patients?

Perhaps the first step is understanding why they occur.

Atul Gawande, MD, MPH is the author of several best-selling books about the medical industry. In The Checklist Manifesto, he discusses the degree of required preparation, as well as the growing specialization of today’s clinicians—and that it’s still not enough to address the increasing complexity of the job without making mistakes.3

He likens the situation to that of pilots. When aircraft became so sophisticated that no individual could safely fly them based solely on experience and expertise, the U.S. Army Air Corps created a simple step-by-step checklist for take-off, flight, landing and taxiing. Nearly a century later, the pilot checklist is still the gold standard for safe flight. Similarly, many aspects of medicine are simply too complex for any individual to carry out reliably from memory or experience alone.

A seminal study by Peter Pronovost, MD, PhD, FCCM of Johns Hopkins Hospital4 took a checklist-like approach to address the ongoing challenge of deaths due to infections from heart catheters. After three months of instituting a simple five-step series of tasks at 103 Michigan hospitals, the bloodstream infection rate dropped from eleven percent to zero. Additional checklist studies demonstrated similarly powerful results and helped inspire Pronovost to dedicate his career to making healthcare safer for patients. He told Dr. Gawande: “The tasks of medical science fall into three buckets. One is understanding disease biology. One is finding effective therapies. And one is insuring those therapies are delivered effectively.” It’s this third bucket where we need help.

Errors and gaps in care have become inevitable consequences of the complexity of today’s medicine and the overload of today’s physicians. When these gaps aren’t identified and closed, opportunities are missed and event-driven, reactive care (instead of longitudinal care) becomes the mode of clinical practice. The result? Outcomes suffer.

This is especially true for clinicians who see a wide variety of patients at a fast pace in increasingly large panels. They desperately need tools to apply appropriate guidelines throughout a diverse patient panel without missing something. And those tools must be as easy to implement within their current practice as checklists have proven to be in hospitals. Because once we can identify patients that need interventions and apply the latest guidelines appropriately, we’ll deliver better care at the individual level and better outcomes at the population level.

And for most of us, that’s what we got into this field to accomplish.





J. Siemienczuk, MD