COVID-19 exacerbates medical error. How can we combat this?
By Juneau Wang, BA(c), Sofia Sherman, BA(c), Enrique Carreras Perozo, BA(c), Elman Leung, BA(c), Thin Yu Yu Hlaing, BA(c)
The novelty of the COVID-19 pandemic has challenged clinicians in an ever-changing clinical climate, which in turn has threatened the wellbeing of patients worldwide. Specifically, the pandemic has increased the prevalence of medical errors. Errors in diagnosis and treatment have persisted throughout history as one of the most common causes of death in developed and developing countries. Organizations like the World Health Organization (WHO) have long been advocating measures aimed at reducing medical error and promoting primary care. World Patient Safety Day, for example, is a public awareness campaign part of the WHO’s platform to reduce medical error. Before COVID-19, avoidable medical error was the third leading cause of death in the United States and cost the United Kingdom over £1 billion annually. Medical error has greatly delayed the recovery of society during the COVID-19 global pandemic. In particular, disease misdiagnosis, equipment unfamiliarity, and clinical exhaustion have hurt healthcare workers and patients.
An infamous case of disease misdiagnosis occurred in Italy during the onset of the pandemic. According to a case study from TIME, many health officials believe the airborne and potentially deadly virus arrived in Italy much earlier than Lombardy’s Patient Zero in February 2020. Before “Patient Zero,” Northern Italy experienced a peak influenza season and an “unusual surge” in pneumonia cases. Italian health workers failed to consider COVID-19 had already spread to Italy; instead, they diagnosed and treated patients with COVID-19 as if they had the “seasonal flu.” Misdiagnosis demonstrated that health workers lacked knowledge of distinguishing diagnostic criterions and that the affected hospitals might have become hotspots for infection, thus worsening the pandemic spread in Italy.
Additionally, a recent study by The Wall Street Journal reported that in hospitals overwhelmed by COVID-19, medical residents were accelerated into clinical roles of which they were unprepared. According to a New York Times op-ed, residents training to be dentists, ophthalmologists, and psychiatrists were required to treat a record-high number of critically ill patients despite being unfamiliar with ICU equipment. Residents at various ICUs struggled with ventilators leading to at least one death.
COVID-19 exacerbated medical errors worldwide through mismanagement due to scarce resources. During the pandemic, amidst employee reduction campaigns to protect employee health and address financial budgetary restrictions, two nurses were forced to set up a vital signs monitor because the organization lacked the necessary staff. The assembly instructions were unclear and complex and the nurses found themselves analyzing the calibration protocols until eventually forced to abandon the task. Precious clinician time was wasted assembling a machine rather than caring for patient: a major crisis management failure.
Healthcare workers have experienced increased exhaustion and stress further leading to iatrogenic error—error caused by ineffective treatment. COVID-19 literally overwhelmed the preexisting prevalence of clinician burnout with reduced staffing models, psychosocial climate of the pandemic, and relentless familial and clinical despair. Qian Liu and coworkers interviewed physicians and nurses in China about their experiences in hospitals and clinician exhaustion. The overwhelming demand for treatment furthered by a lack of knowledge and unfamiliar medical equipment led to healthcare workers experiencing their own emotional and physical stress while having to continue their duties. One nurse recalls:
[…] it feels clumsy to walk and do procedures. Although I am good at venepuncture, I cannot feel blood vessels to draw blood with three layers of gloves [… ] My glasses and protective goggles are blurry because I am hot […] I am very anxious and irritable, because I have so much work to do but I can’t see well.
Long shifts, incessant critical influx demand, overwhelming anxiety, and COVID-19 physical barriers like restrictive PPE (personal protective equipment) and social distancing have further decreased healthcare workers’ ability to perform. Rodrigo Tejos and coworkers from Chile and the United Kingdom detailed a pandemic-related example of treatment error: hospital workers took tissue samples from a patient suffering from breast reduction complications and infection. When sent to the microbiology laboratory for analysis, the sample was mislabeled with those of a different patient. The investigation found that the junior nurse responsible for labeling the specimens caused the error due to stress and exhaustion — the nurse was working extra shifts to cover for quarantined colleagues.
Since the COVID-19 pandemic exacerbates the presence of medical error we must find an effective way to address the operational causes. According to the same article by Rodrigo Tejos and coworkers, a potential solution to the lack of adequate rest between shifts (that plagued the aforementioned junior nurse) is better organization and distribution of teams. Unexpected crises — like natural disasters or pandemics — demonstrate the fragility of healthcare systems. Creating teams of workers could harbor units of support that help everyone get through daily stressors. Not only should rotations be planned ahead of time, but management needs to actualize its commitment to invest in their healthcare workers’ welfare.
Furthermore, solutions to combat inexperience and unfamiliarity could entail better supervision of medical workers and online induction modules for new members. The adaptation of educational modules that provide significant information, such as the location of spaces, the equipment in each room, and the contacts of all supervisors could facilitate patient care, particularly for new residents and in case of major crises. And perhaps most importantly, hospitals need to allocate and prioritize time for workers to access these online modules before they are thrown into emergency situations or redeployment.
Other potential solutions to increase effectiveness during crises include the implementation of video calls, artificial intelligence (AI), and live-feed technology. In the scenario of the nurses trying to install a vital monitor, maintenance staff could be “on-call” from home assisting with technical or logistical issues remotely. Additionally, investing in video infrastructure would also allow clinicians at home to live-feed coach residents, especially those redeployed from other clinical areas, in patients’ rooms and clinical spaces as they would on-site. Although such practices may be expensive, it would lead to significantly quicker and more efficient solutions and could be built into workforce reduction and redeployment plans.
Building AI interfaces is not limited to just hospital systems, manufacturers and other external vendors can assist clinicians in valuable ways. The nurses unfamiliar with the vital signal monitor could have benefited from having a manufacturer built AI guide allowing them to effectively work with the special equipment while keeping personnel safe. Furthermore, a live-feed AI could help workers physically navigate through unfamiliar hospital units.
One real-world example where similar ideas were implemented is how the West China Hospital of Sichuan University created a 5G Gigabit multimodal network that covered the entire Sichuan Province geographic area and its multiple cities. Disaster relief funds helped fund the telephone hotline and smartphone app to provide free consultations as well as prescription services including delivery. Telemedicine and internet hospitals using multidisciplinary teams allowed those unable to travel, such as the elderly, those in quarantine, or pregnant women to receive necessary diagnoses including remote CT scans and behavioral health interventions. In the United States, the emergency CMS waiver for telehealth, as discussed by Bioethics Alliance’s Research Assistant Halle Paredes, also allowed many hospital systems to continue to care for their patients especially those who closed non-acute care units to allow for redeployment of staff, minimize COVID spread, and as a stopgap measure for hemorrhaging expenses. The doctor-patient relationship was restored and these example serves as a blueprint for other countries in the value and unlimited opportunities of network live-feed technology among clinicians, non-clinical employees, vendors, and patients.
Ultimately, it becomes the responsibility of public health experts across the world to both recognize and prioritize the dangers of medical error and design crises responses that more efficiently and effectively ensure patient health. Although COVID-19 represents a difficult transition, healthcare management must not only recover but improve its healthcare disaster response systems.
Juneau Wang is a Boston University BA candidate class of 2024, majoring in Cellular, Molecular, and Genetic Biology and minoring in Voice Music Performance. He currently works as a research assistant at the Denison Lab of Perceptual Psychology and the Ikezu Lab of Molecular Neurotherapeutics. He is interested in patient-centered care, preventative medicine, and marine science.
Sofia Sherman is a Boston University BA candidate class of 2024, majoring in Neuroscience and minoring in Public Health. She is interested in the practice of clinical medicine focusing on pediatric oncology and advancing research on carcinogenesis to enhance cancer treatment and prevention.
Enrique Carreras Perozo is a Boston University BA candidate class of 2023 majoring in Biology with a specialization in Cell Biology, Molecular Biology and Genetics and Minoring in Visual Arts. He plans to study medicine, and he’s interested in medical illustration and healthcare accessibility.
Elman Leung is a Boston University BS candidate class of 2024, majoring in Human Physiology. He is interested in the practice of sports medicine and implementing technology for treatment and recovery.
Thin Yu Yu Hlaing is a Boston University BS candidate class of 2023, majoring in Human Physiology. She plans to study medicine, with particular interest in dermatology and public health.