I think if I had done this five or six years ago, I'd have been taken out and lynched," says Robert Wachter of his new book, Internal Bleeding: The Truth Behind America's Terrifying Epidemic of Medical Mistakes.
What makes the book Wachter co-authored with his physician colleague Kaveh Shojania less dangerous to its authors are the new focus on healthcare quality and To Err is Human, the 1999 report by the Institute of Medicine, which famously concluded that as many as 98,000 people die each year from medical mistakes. These days, the IOM report is tame in comparison with reports being issued almost weekly on the perils of being a patient.
"Medicine has really evolved on this issue," Wachter says, and the cover art on his book, an X-ray image of a patient's abdomen with a left-behind pair of forceps, no longer is so arresting.
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. Wachter says he included two of his own mistakes in the book. "One was a near miss and one a direct hit."
Wachter and Shojania founded the Quality Grand Rounds series of cases 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, at ahrq.gov.
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 says. 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.
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.
"In some ways, educating doctors and nurses about this is harder because we come in with our own biases, and they are wrong," he says.
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 and Shojania are both hospitalists at UCSF Medical Center, San Francisco.