Contrarian: Big Medicine, Small Minds
Michael Cohen says he doesn’t consider himself a genius, but the MacArthur Foundation thought highly enough of him last year to include the Huntingdon Valley pharmacist among just 25 recipients of its famous “genius grants.” Cohen, who heads the Institute for Safe Medication Practices, will get $500,000 over the next five years to continue his three-decades-long campaign to get drug makers, hospitals and medical personnel to stop accidentally killing their patients with overdoses and mistaken medications. MacArthur lauded Cohen for taking the initiative 30 years ago to start up a confidential error reporting system so that dangerous patterns in mis-medication could be detected and remedied. It’s telling that the nation’s hospital heads were either too timid or too blind to start such a system on their own. Only in medicine could a humble pharmacist from Philadelphia be considered a genius for tackling the industry’s most serious and obvious failings.
Each year, drug-related screw-ups in hospitals kill or injure hundreds of thousands of people. Medical errors of all kinds kill about 100,000 Americans
annually — more than car crashes, breast cancer and AIDS combined. In effect, the nation’s medical personnel carelessly knock down a World Trade Center full of victims every nine days. Confused directions, preventable infections and mistaken medications leave countless other patients debilitated or permanently disabled. The longer your hospitalization, the more you’re at risk. Sick people might be safer in a West Virginia coal mine than they are in a West Philadelphia teaching hospital.
The opportunities for error inevitably increase as medicine becomes more complicated and specialized. But while medical technology keeps producing new miracles every day, critics within the field complain that medical safety technology has long lagged a decade or more behind the curve and shows no sign of catching up. For instance, in 2003, Cohen’s institute presented awards to three makers of intravenous drug pumps that sound an alarm if a nurse accidentally punches in an overdose. This astonishing achievement came along 19 years after the invention of my Apple Macintosh, which also gives a warning beep — when you try to reformat the household grocery list. Did it really take almost two decades to make drug pumps as idiot-proof as a Mac? These companies shouldn’t be up for awards. They should be up on charges.
People die in hospitals for reasons that are unspeakably ridiculous. Nurses have cut patients off their life-sustaining drugs because “D/C” in doctor-scrawl can mean two different things — discharge, or discontinue. Poor handwriting and clever drug-branding induces nurses to make fatal errors by confusing Flomax with Volmax and iodine with Lodine. Forget about the federal No Child Left Behind Act. Without a federal No Patient Left for Dead Act, some children will never reach school age.
To the rest of the modern industrial world, forcing workers to rely on scribbled instructions and confusing product labels is antediluvian idiocy. It invites mistakes and murders the bottom line. Wal-Mart has so highly automated its bar-coded supply chain that for a decade or more it has been able to tell Tylenol from Ty-D-Bol on a store shelf half a world away from its Arkansas headquarters. The Food and Drug Administration didn’t even require bar codes on drug packages until this year, 32 years after the first pack of gum was price-scanned.
You’d think it wouldn’t be that hard to goof-proof the nation’s drug-dispensing system up to Wal-Mart’s circa-1995 technical standards. On the other hand, consider that doctors and nurses can’t be counted on to wash their own hands. At least 90,000 patients die every year from hospital-borne infections, often spread by health-care workers who don’t wash up between patients. It’s a well-known problem, and yet studies show that hand-washing rates among medical personnel stubbornly remain below 50 percent.
Doctors are the big, immovable obstacle at the core of the problem. They are members of the wealthiest and highest-status profession in society, so it’s impossible to force them to do anything. Holding them to any protocol — don’t scribble confusing directions, count your surgical sponges before sewing up, wash your goddamn hands — is hopeless. At the end of every study of chronic patterns of hospital errors is a pathetic list of “recommended” measures that tippy-toe around each physician’s prerogative to save lives — or sacrifice lives — as he or she sees fit.
During the Clinton administration, there was actually an attempt to enact a federal law that could have been called No Patient Left for Dead. The goal was to legislate an independent agency for health care akin to the Federal Aviation Administration, which regulates airline safety. Once the medical lobby got hold of the bill in Congress, however, it stripped out almost all the safety mandates. By the time George Bush signed the Patient Safety and Quality Improvement Act into law last year, safety compliance was a voluntary step that hospitals are free to ignore.
Michael Cohen says he plans to take his MacArthur bucks and start a project to prevent pediatric drug errors. I can’t presume to tell our local genius what to do, but right now, with the MacArthur imprimatur fresh in the public mind, Cohen might be the only person in America with the moral authority to shame the medical directors of our top hospitals into using this new law to save lives. While he’s at it, he might persuade Wal-Mart to consult with the hospitals and drug makers so we’ll have a health-care delivery system for drugs as error-proof as the one that supplies us with MoonPies, mouthwash and t-shirts. It’s in Wal-Mart’s interest to help out, too. With 60 percent of the country shopping there, hospitals are knocking off Wal-Mart customers at a rate of 60,000 a year.
Fix it the Wal-Mart way, folks, and fix it now, because in the coming decade, you’re bound to kill yet another million people who trusted you to care for them. Sure, it might feel kind of demeaning for all you big-city doctors to learn about saving lives from a band of union-busting hick retailers in Arkansas, but take that as a sign of how unforgivably hidebound and small-minded your profession has become. It ain’t brain surgery to figure out how to stop poisoning your patients. Stop acting like it is. b
E-mail: nweyrich@phillymag.com
