HJAR Jul/Aug 2024

HEALTHCARE JOURNAL OF ARKANSAS I  JUL / AUG 2024 23 flush (something necessary to keep intravenous lines open and running) to an ICU patient but was really a vial of insulin, causing subsequent death from low blood sugar. The poor pa- tient, their family, and the well-meaning nurse became victims of a system that had failed to eradicate preventable harm. The poor nurse, who very likely went into healthcare because of a passionate desire to help others, was equally devastated by the reality that their actions re- sulted in death. This episode happened in an era of healthcare where the unrealistic expec- tation was that of human perfection. In other words, nurses and doctors were expected to be perfect and not prone to human error. But humans are inherently imperfect. At the time, the hospital that employed the nurse resorted to blame, likely to protect themselves from liti- gation, and fired the nurse. The nurse, who very likely suffered from post-traumatic stress disor- der because of that tragedy, probably reflected on the events of that fateful day every day for the rest of their life. Fortunately, this is an area where quality improvement science has made considerable progress as we now understand that type of mistake to be a “systems” error, where the nurse had been set up for failure. The vials of heparin and insulin looked very similar and were co-located right next to each other on the shelf. It was such an easy mistake to make. Nowadays, there are systems and processes in place that ensure such mistakes are far less likely to happen by designing the vials very dif- ferently and placing them in very different loca- tions on shelves to negate the risk of human er- ror. Chasing “zero,” meaning zero preventable harm, has become a mantra at many hospitals, and the Leapfrog group makes grades for hos- pital safety transparent to the public to help consumers understand which hospitals are now ranked among the safest places to receive care. Getting it right The Rotterdam criteria for polycystic ovary syndrome, or PCOS, was published in 2003. The criteria required two of three criteria to diagnose PCOS: 1) signs or symptoms of hy- perandrogenism (i.e., too much testosterone causing abnormal hair growth), 2) irregular menstrual periods, or 3) polycystic ovaries on imaging. Approximately 10% of women in the U.S. meet these criteria for a diagnosis of PCOS. That means 1 out of every 10 women I encountered during my initial 15 years in pri- vate practice should have fulfilled the criteria solve a given problem. Our thinking becomes constrained by conventional approaches used in healthcare delivery and substantially limits our ability to conceptualize novel solutions. Not doing what we know largely becomes a function of failure to stay up to date with the lat- est scientifically proven advances. I recall being a resident when a former professor and mentor of mine asked us what percentage of patients suffering from heart failure with reduced ejec- tion fraction (known as systolic heart failure at the time) were routinely being prescribed the scientifically accepted gold standard pharma- cologic treatment of a drug class known as an ACE inhibitor. We had learned in medical school, and then repeatedly during our resi- dency, that ACE inhibitors decreased mortality in patients with heart failure. Pathophysiology was easy to understand. These medications di- lated arteries distal to the heart, thus reducing the afterload or pressure that the heart had to pump against, making it easier for the heart to squeeze and eject its volume of blood to sup- ply vital oxygen to the body’s tissues. I think we all naturally assumed that the answer should be around 90% or so, meaning that 90% of pa- tients with heart failure were being prescribed a medication that was known to be lifesaving. I was aghast when he told us that the true answer was 20%, meaning that only 20% of patients were being prescribed this mortality-reducing medication. He went on to cite studies dem- onstrating the 17-year lag in medicine between knowledge creation and knowledge transla- tion, meaning it would take on average about 17 years before scientific advances became regularly incorporated into the practice of medicine. How could this be? How could doc- tors become so out of date that they failed to apply knowledge that, for us in residency, was considered basic to caring for a fellow human being. I made a silent vow to never allow that to happen to me — a vow that, like so many of my colleagues, I found myself breaking repeat- edly in the busiest years of my private practice. Knowing what to do and doing it but doing it wrong is the third area of fertile ground for mistake making in healthcare delivery. Before the permeation of electronic medical records in healthcare, this category included things like medication errors because of illegible hand- writing. It also included such heartbreaking and catastrophic stories as a patient dying when a nurse grabbed a bottle that looked very much like heparin to administer a routine heparin Obesity is such an important disease and epidemic impacting our society in increasingly devastating ways that we have now devoted the past three articles in this journal to discuss- ing it. We will devote the next couple of articles to discussing three more tangentially related issues: polycystic ovary syndrome, metabolic syndrome, and metabolic-associated steato- hepatitis (or fatty liver disease). All three con- ditions have a shared commonality of insulin resistance, often associated with central obe- sity, where excess accumulation of fat creates a toxic milieu of health consequences. Their pathophysiology is complex, though, and obe- sity is not an essential prerequisite. Although these conditions are unquestionably impactful to both affected individuals and our society, traditional healthcare has done a relatively poor job of managing them effectively. I know with certainty during my own years of private practice that I did not even understand PCOS all that well, much less manage it effectively. And if we were nailing the treatment of meta- bolic syndrome and fatty liver disease, then the latter would not be projected to become the leading cause of liver failure within the next de- cade or so. Indeed, the common theme of this entire series of articles is that there is virtually nothing in healthcare that cannot be improved. Getting it wrong There are so many ways to make mistakes in healthcare, all with enormous implications for the patients we truly want to do right by, but they can generally be grouped under three large categories: 1) We don’t know what to do, 2) we don’t do what we know, or 3) we know what to do and we do it, but we do it wrong. Not knowing what to do is generally a func- tion of the lack of validated scientific knowl- edge around a particular problem. Either we have not performed a placebo-controlled randomized clinical trial to study the issue and answer our questions, or the problem to be solved is not amenable to such a random- ized trial in the first place. In the case of the latter, we may try to use other means such as observational studies, cohort studies, or case control studies to find answers, all of which may be confounded by various forms of bias. Furthermore, as discussed in our last article on obesity management, under the currently predominant transaction-based economics of healthcare, we allow remuneration for services rendered to limit our imagination of how to