Stop Flushing Medical Errors Down the Toilet

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We have explored in previous writings how biological systems and human physiology can model elegant solutions for the design and operation of complex hospital buildings, suggesting ideas for non-disruptive alarm signals, mechanical systems monitored by information technology to increase patient safety, and heating and cooling layouts that conserve energy.

Another essential component of safe patient care is prompt reporting of medical errors, errors that may or may not have actually harmed the patient. Collecting this data is essential so that physicians and nurses can understand and correct the underlying causes for the error.

Image courtesy of INDA:

Despite both mandated and voluntary reporting protocols, finding accurate data on the number and cost of medical errors is almost impossible. Recently a comprehensive tool, the Institute for Healthcare Improvement released the Global Trigger Tool, developed to capture data on errors. This tool, which still underestimates the true incidence of mistakes, revealed that less than 10% of errors are actually reported!


Why does this reporting deficit exist?

Clinicians avoid reporting errors because they fear damage to their reputation and career, as well as litigation, or they lack training on how best to handle these difficult conversations. How can an environment protected from these pressures be created, one that encourages clinical staff to view errors as opportunities to improve the system rather than as personal failures?

Can mammalian physiology model a solution to this cultural and behavioral problem universal in healthcare?


Yes! The kidney models an answer

The kidney is a remarkable organ, responsible for both filtering soluble waste products from our blood and for maintaining a strict fluid and chemical environment in order for us to survive. This balance of fluid intake with urine output must occur despite widely varying outside climates to protect us from dehydration in dry environments as well as from over-dilution and bloating when large volumes of fluids are consumed. When we drink excess water, the kidney can excrete very diluted urine with a concentration of about one-sixth of the rest of body.  Conversely, when there is a deficit of water, the kidney can excrete urine concentrated up to four times greater than the surrounding tissues. Incredibly, the kidneys maintain this hydration balance while processing more blood and bodily fluids than any other organ in the body; 180 liters or 47 gallons per day of which 99% is reabsorbed back into our body. The kidney accomplishes this filtering and concentrating feat in the midst of tightly regulated surrounding tissues.

Healthcare kidney

Protection of the whole body from dehydration or bloating while surrounded by incompatible concentration gradients, is achieved in a protected “inner sanctum” zone in the center of the kidney. This zone, known as the renal medulla, is where chemical products and fluids are balanced, operating as if oblivious to the conflicting concentration gradients in cells only millimeters away.

To accomplish this fluid filtration and concentration feat, the cells of this zone use unique molecular tools to survive and operate in this environment, such as the use of “chaperone molecules” to protect active kidney cells, and pathways to mobilize glucose for fuel in the absence of oxygen.


How does the kidney relate to physicians and nurses reporting medical errors?

Hospitals need a “renal medulla” protected space, a safe real or virtual space, where clinical staff are protected from the surrounding hostile environment, a space that rewards reporting and puts a high value on open communication to ultimately support behavior which is beneficial to patients, the hospital budget, and to the physicians and nurses who are involved in the error. Only with these safeguards in place can clinicians and administrators reveal, analyze, and learn from these events, ultimately preventing future tragic results from accidents caused by human and system errors. Perhaps this protected environment, consists of a conference room with soundproof walls. or an IT data storage compartment impenetrable to insurance companies, auditors and attorneys. At the very least, there needs to be a core attitude of trust and openness for the physicians, nurses, and administrators.

If your hospital or institution has already embarked on creating a protected zone where errors can be revealed and understood for improved patient safety, please share your ideas below so others can join you in this work.

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