Free Complications by Atul Gawande Page A

than thirty thousand hospital admissions in New York State. The study found that nearly 4 percent of hospital patients suffered complications from treatment which either prolonged their hospital stay or resulted in disability or death, and that two-thirds of such complications were due to errors in care. One in four, or 1 percent of admissions, involved actual negligence. It was estimated that, nationwide, upward of forty-four thousand patients die each year at least partly as a result of errors in care. And subsequent investigations around the country have confirmed the ubiquity of error. In one small study of how clinicians perform when patients have a sudden cardiac arrest, twenty-seven of thirty clinicians made an error in using the defibrillator—charging it incorrectly or losing too much time trying to figure out how to work a particular model. According to a 1995 study, mistakes in administering drugs—giving the wrong drug or the wrong dose, say—occur, on average, about once every hospital admission, mostly without ill effects, but 1 percent of the time with serious consequences.
    If error were due to a subset of dangerous doctors, you might expect malpractice cases to be concentrated among a small group, but in fact they follow a uniform, bell-shaped distribution. Most surgeons are sued at least once in the course of their careers. Studies of specific types of error, too, have found that repeat offenders are not the problem. The fact is that virtually everyone who cares for hospital patients will make serious mistakes, and even commit acts of negligence, every year. For this reason, doctors are seldom outraged when the press reports yet another medical horror story. They usually have a different reaction: That could be me. The importantquestion isn’t how to keep bad physicians from harming patients; it’s how to keep good physicians from harming patients.
    Medical malpractice suits are a remarkably ineffective remedy. Troyen Brennan, a Harvard professor of law and public health, points out that research has consistently failed to find evidence that litigation reduces medical error rates. In part, this may be because the weapon is so imprecise. Brennan led several studies following up on the patients in the Harvard Medical Practice Study. He found that fewer than 2 percent of the patients who had received substandard care ever filed suit. Conversely, only a small minority among the patients who did sue had in fact been the victims of negligent care. And a patient’s likelihood of winning a suit depended primarily on how poor his or her outcome was, regardless of whether that outcome was caused by disease or unavoidable risks of care.
    The deeper problem with medical malpractice suits is that by demonizing errors they prevent doctors from acknowledging and discussing them publicly. The tort system makes adversaries of patient and physician, and pushes each to offer a heavily slanted version of events. When things go wrong, it’s almost impossible for a physician to talk to a patient honestly about mistakes. Hospital lawyers warn doctors that, although they must, of course, tell patients about injuries that occur, they are never to intimate that they were at fault, lest the “confession” wind up in court as damning evidence in a black-and-white morality tale. At most, a doctor might say, “I’m sorry that things didn’t go as well as we had hoped.”
    There is one place, however, where doctors can talk candidly about their mistakes, if not with patients, then at least with one another. It is called the Morbidity and Mortality Conference—or, more simply, M & M—and it takes place, usually once a week, at nearly every academic hospital in the country. This institution survives because laws protecting its proceedings from legal discovery have stayed on the books in most states, despite frequent challenges. Surgeons, in particular, take the M & M seriously. Here they cangather behind closed doors to review