Bad Outcomes of Questionable Medical Decisions

IN RESPONSE:

Dr. Kessler argues that in the patient we discussed, a more conservative approach to managing pericardial effusion would have been preferable. The cardiologist in this case (who was also a respected clinician at a respected institution) made a different decision. Our experience in formal studies of physician peer review suggests that reviewers make highly variable assessments in most episodes of patient care (1). Assessments of clinical decision making are not very precise, although there is evidence that they are valid in that they correlate with other measures of quality (2). Dr. Kessler also suggests that “errors” should be assessed independently of outcome. While we might want to blind reviewers to outcome in a measurement procedure, we shouldn't waste our time worrying about process problems unless they are causally linked to risk for an adverse outcome in a population of similar cases (3).

Dr. Nilson and Drs. Weeks and Bagian argue that there is value to looking, through retrospective reviews or root-cause analyses, to find ways to reduce risk and improve care. We agree. In fact, we suggest (as we did in our paper) that a variety of new methods of monitoring and reviewing adverse events, including root-cause analysis, may enhance our ability to investigate causes. However, it seems premature for credentialing bodies or peer pressure to mandate the use of a specific method without evaluation.

Patient safety is not likely to be enhanced by making substantive changes in clinical or organizational systems based on low standards of evidence, that is, case reports and uncontrolled studies with overly ambitious extrapolation (1, 3). At the local level, where a root-cause analysis is by definition anecdotal, there is a danger that the pressure to find a vulnerability and change the system can lead to more harm than benefit if processes are modified based on an erroneous assessment of cause and effect.

A potential danger of declaring a “war on errors” is that the invoked sense of crisis impels us to suspend our normal critical assessment of the evidence for risk versus benefit in a push for action. While crisis does demand action, frequently the argument that a crisis exists becomes political and transcends the world of science. For most patient safety problems, we feel that the inherent risks of shooting from the hip should lead us to another course of action: carefully taking aim at identifiable targets.

• Copyright ©2004 by the American College of Physicians