Robert Wachter, M.D., was on the phone this morning, two days before his book was to be officially released, and his voice bore the tone of both proud accomplishment and wary excitement. Think of how a satisfied man might sound sitting back after boarding up his home with three-quarter-inch plywood -- and waiting for a hurricane to strike.
"I think if I had done this five or six years ago, I'd have been taken out and lynched," Wachter said. He laughed, but there is more than a little truth to his joke.
Like the 1999 Institute of Medicine Report on medical errors, the new book by Robert Wachter, M.D., and colleague Kaveh Shojania, M.D., is as blunt as a bludgeon.
The IOM's "To Err is Human" remains in constant reference today, more than four years after its publication, in part because on its opening page its authors hit hard, suggesting as many as 98,000 people a year die in U.S. hospitals due to preventable medical errors.
Similarly, the title of the two California physicians' new book, to be released Wednesday, is a gripper by itself: Internal Bleeding: The Truth Behind America's Terrifying Epidemic of Medical Mistakes.
Then there is the stomach-catching cover art: an X-ray image of a patient's abdomen with a left-behind pair of forceps in plain sight.
"Medicine has really evolved on this issue," Wachter said. It has come, he said, from everybody in medicine reassuring themselves that things are not so bad to realizing that, in fact, "Yeah, it's very bad," and needs to be fixed.
Wachter, in an interview with Modern Physician, said the IOM report and the many discussions on medical errors in its wake will have inoculated his peers to the harshness of this newest exposure of medical fallibility.
At its heart, Internal Bleeding examines about 20 case studies involving serious medical errors with an emphasis not on affixing individual blame, but rather on highlighting systemic error.
Aside from a few headlining cases, including those cited by the IOM in which the patient's names were mentioned, most of the cases in Internal Bleeding were gleaned from Wachter's own personal contacts with fellow physicians and were de-identified by person and place.
Wachter said he included two of his own mistakes. "One was a near miss and one a direct hit."
Wachter and Shojania founded the Quality Grand Rounds series of case studies started several years ago in the Annals of Internal Medicine and are now also editor and deputy editor, respectively, of the "Morbidity and Mortality Rounds on the Web" forum and journal on the Web site of the federally funded Agency for Healthcare Research and Quality.
Their work applies the case-study approach so familiar to physicians in solving clinical problems to a systems approach to patient safety.
Internal Bleeding grew directly out of that work, Wachter said. In fact, their publisher offered them a book deal after reading an article in the New York Times written about one of their Quality Grand Rounds case studies, he said.
The book was written with an eye to finding what Wachter describes as a "sweet spot" between readability for the lay person and packing enough clinical detail and analysis of a systems approach to problem solving to be a guide for clinical professionals seeking to improve, Wachter said.
"I hope it's useful and accessible to both," said Wachter, but clearly his sympathies are with fellow physicians. "I've worked in a lot of places and learned nothing about how to fix errors. It's not in any core curriculum. In some ways, educating doctors and nurses about this is harder because we come in with our own biases, and they are wrong."
Wachter, the IOM and many others in the systems approach to error reduction make the argument that physicians are trained to be independent thinkers and self-reliant. Therefore, when an error occurs, it is automatic thinking to assess personal failure when in fact, the system itself, for all its technological advances, is woefully lacking in built-in safety features.
Wachter likened healthcare to a Ferrari sports car without airbags or seat belts.
"Patients and their caregivers have been let down by the system they trust," Wachter said, a line he lifted from the book's dedication.
"You're not going to build the flawless individual," Wachter said. "We're not going to fix this by getting brighter individuals to work harder."
Wachter and Shojania are hospitalists at University of California, San Francisco Medical Center, where Wachter serves as chief of the medical service. There he directs the UCSF hospitalist program and chairs the UCSF Patient Safety Committee.
Wachter, the first president of Society of Hospital Medicine, also was director and an editor of Making Healthcare Safer: A Critical Analysis of Patient Safety Practices, produced for the Agency for Healthcare Research and Quality and published in 2001. Shojania authored six chapters in the report.