di
Eminè Meral Inelmen, Enzo Manzato

Dipartimento di Scienze Mediche e Chirurgiche
Cattedra di Geriatria (Direttore: E. Manzato)
Università degli Studi di Padova

INTRODUCTION
Although medical error (ME) is a public health burden (1), instead of learn and prevent, we often use to hide this problem. We found that it is too easier to accept some degree of MEs as the inevitable product of today's increasingly complex patient care, rather than exploring why the error occurred. Because of the fear of lawsuits, of humiliation, of job loss we prefer not to talk about this topic. In fact, the public believes that doctors responsible for errors with serious consequences should be sued, fined, and even subject to suspension of their professional license (2). Thus, when ME occurs, the reaction in medical settings is most commonly an attempt to fix blame and to punish someone (3). Fear, reprisal, and punishment produce not safety, but rather defensiveness, secrecy, and enormous human anguish (3).

The risk of MEs is not the same in all cases: the sickest patients who are subjected to multiple interventions, and who remain in hospital longer, are more likely to suffer serious injury as a result of medical mistakes (4); so it is reasonable to conclude that errors are committed more frequently in the geriatric field (1). Sadly, diagnostic errors have received little attention in literature, especially in geriatrics, although the elderly population has been increasing in the last few decades (1).

Here we focus attention on this alarming issue and stress the need of creating strategies against MEs in geriatrics.

EPIDEMIOLOGY OF THE MEDICAL ERRORS
In the last decades we are seeing MEs as an "epidemic" condition (1). One million injuries and nearly 1000.000 deaths seem to occur in the United States annually as a result of mistakes in medical care (5). It is as a jumbo crash occurs every two weeks in one year! In fact, one estimate is that a modern passenger would have to fly continuously for 2O.OOO miles in order to reach a 50% chance of injury in an airplane accident (3). Actually there is no way of knowing exactly how many people died from a particular procedure. There are still no codes for MEs.

POSSIBLE CAUSES OF MEDICAL ERRORS
Blendon et al. (2), conducted a survey on the possible causes of MEs: understaffing of nurses in hospitals and overwork, stress, or fatigue on the part of health professionals were the two main causes reported by physicians, while the top four causes considered to be very important by public were physicians' not having enough time with patients; overwork, stress, or fatigue on the part of health professionals; failure of health professionals to work together or communicate as a team; and understaffing of nurses in hospitals.
Work-loads of healthcare staff has to be avoided: safe performance cannot be expected from workers who are sleep deprived, who work double or triple shifts

(6). After 24 hours of work without sleeping , the capacity of a healthcare operator is similar to a drunk person! (7).

POSSIBLE CAUSES OF MEDICAL ERRORS IN GERIATRICS
Achieving an accurate clinical diagnosis is especially difficult in elderly patients, many of whom will have multiple pathology and whom presentation of disease may be atypical. Each older patient often has a different and very complex clinical scenario. Accuracy of clinical diagnosis declined with increasing patient age, so that only 47 % of clinical main diagnosis were confirmed at necropsy in 295 patients aged more than 75 years old (8). For example, the diagnosis of appendicitis in elderly is not always easy. Especially in demented, non collaborating, bedridden elderly patients, medical history or physical examination may lead to misdiagnosis because they can be incomplete, poorly performed, or wrongly interpreted (1). In addition, excessive reliance on laboratory test results may cause confusion because of the co-morbidities (1). The most misleading symptoms in elderly are vertigo, imbalance, falls, disorders of consciousness.

Hence, in geriatrics the clinical diagnosis is not always the aim: we often cure only the symptoms for which the patient has been recovered. Because of the large use of drugs and the occurrence of interactions we can err in the treatment. In fact, adverse effects of drugs are very frequent in advanced age; although iatrogenic injuries observed in autopsies are frequent cause of death, approximately 90 % of them are not described in clinical reports (9). Inappropriate invasive diagnostic procedures can be also considered as errors, as they can harm the old patient without any benefit.
A study based on autopsy of 311 subjects has shown that patients with obese-level BMIs seem to be at increased risk for clinically unsuspected diagnoses, compared with underweight and normal weight populations (10). As obesity is becoming an "epidemic" condition at all ages (11), misdiagnosis is supposed to increase in the future because of both increases of elderly and obese populations.

It is interesting to note that there is a greater accuracy of diagnosis in the elderly by specialist geriatricians compared with non-specialist units, although the levels of misdiagnosis are still high (12).

REPORTING MEDICAL ERRORS
The great problem of not having the precise prevalence and magnitude of ME, even if it is probably enormous, is the under-reporting of errors (4). Universal under-reporting undermines the ability to measure error accurately (4). But who is responsible of reporting MEs? We are supposed to be the reporters but we are afraid of being sued so usually it is the patient or the patient's surviving family. If no one notices the error, it is never reported.
We should learn error-reporting in our training and use it but, unfortunately, the problem is not only to be educated to report MEs. In USA some states have mandatory reporting programmes for error resulting in serious patient harm (13), but this information is used almost exclusively to punish individual practitioners or healthcare organisations (5). Reporting will occur only if practitioners feel safe doing so and becomes a culturally accepted activity within the healthcare community (13). We need freedom from punishment, which is possible only with a voluntary reporting programme (13). We should like to tell anyone about our bad mistake but we are afraid of patient's anger and worse than this, of court punishment. To report in this way can be compared to a "liberator confession". If we will "confess" we can avoid to be "the second victim", as Wu (14) calls, feeling the sense of guilt or remorse. Hence, we need a legal protection if we are supposed to report our error. Buetow (15) suggested that patients "make errors too" and they have to be considered "morally" responsible of their errors: in fact, they may forget to do certain things, such as attend for a planned therapies, or fail to read medication labels and instructions carefully. This can be more frequent among elderly patients who are not able to read because of visual reduction or because of cognitive decline.

AUTOPSY: A WEAPON AGAINST MEDICAL ERRORS
There exists a general perception that necropsies are not longer necessary as ante-mortem diagnosis identifies the principal cause of death and other clinically significant diagnoses in the vast majority of cases (16). This is not true: the best method to improve the accuracy of our diagnosis, especially in the geriatric patients (17), is by obtaining an autopsy every time one of our patients dies. Autopsy is still considered as the gold standard for diagnosis (1). Autopsy studies have provided the source of our knowledge to be applied to future causes, because detect diagnostic errors, investigate and discover unsuspected diseases, enhance new therapeutic modalities and almost always recognize causes of death. Autopsies have also an important role in monitoring quality among populations with an increased proportion of geriatric and obese patients with co-morbidities (18). Despite the acknowledged value of this post- mortem procedure, hospital autopsy rates have fallen to only 10 % of deaths and this declining is worldwide (19, 20), especially in the geriatric age (21, 22). However, in a more recent study it was found that despite a marked decrease in the total autopsy rate, the geriatric autopsy is rising (17).
Among the causes of this autopsy rate's decline may be costs, fear of malpractice litigation, and advanced in medical technology (19). In addition, although autopsy is requested, permission is refused because of resistance by relatives or by an inadequate approach by medical staff (23). The most frequent reported reasons for this resistance are disfigurement of the body, stress of permitting autopsy, and lack of information about autopsy (24). When it comes to geriatric patients, another reason for opposition to the procedure maybe that relatives consider an autopsy to be futile when conducted on an old body (1).

Advances in technology such as ultrasound, computerized tomography, and radionuclide scans have not reduced the value of the autopsy (1). The rate of misdiagnosis detected at autopsy (about 40 %) did not improve from 1960-70 to 1980 after the new technologies became widely used (25). Ermenc (26) reviewed the autopsy records of 1792 deceased persons and compared the clinical and post-mortem diagnosis: the diagnoses in total agreement were only 49,30%.

Such technologies are a double-edged sword and we must judge carefully the results of every diagnostic procedure: even if they provide conclusive new information in about 30% of cases, they also contribute directly to false-positive or false- negative diagnosis in 6%-9% of cases (27). Particularly in the old, in whom virtually all organs are damaged and only patchy structural and functional information is available, we do not fully understand the complex interactions that are at play (28). Then, it is essential for us to relate pathologic diagnostic findings to the history, physical examination, laboratory results, and other technical data: when considered alone, diagnostic methods are misleading in high percentage of cases (27). It has been showed a high percentage of incorrect diagnosis of the clinicians who were sure about correctness of their diagnosis; particularly, there was a correlation between incorrect diagnosis and increasing age (23), although not confirmed by a further study (29). In those cases in which hospitalization exceeded one month, there was an increase in misdiagnosis (23).

More recently, of 53 autopsy series identified, 42 reported clinically missed diagnosis perhaps because only more difficult cases are now selected (30).

Another explanation why the misdiagnosis rate has not decreased over the years can be the pitfalls in correctly diagnosing diseases in older patients (27). The increased life expectancy in industrial countries and the resulting higher proportion of older patients with multiple diseases or atypical cases may contribute to the unchanged rate of diagnostic errors (27).

The most frequently overlooked treatable diagnoses are pulmonary emboli (missed in 63 %), myocardial infarctions (missed in 32%), infections (missed in 19%) and neoplasms ( missed in 9%) (25). Pulmonary embolism- common in advanced age- can be particularly difficult to diagnose because the underlying thrombosis is diagnosed clinically only 15-20 % of the time, and it could be difficult to differentiate the pulmonary embolus from a myocardial infarction (27). Conversely, myocardial infarctions may be misinterpreted clinically as pulmonary emboli, especially in the presence of other major underlying diseases (27). It is interesting to observe that myocardial infarcts as a cause of death, are more often seen in elderly women than in men (17). The cause of death significantly differ in demented and non demented elderly patients: bronchopneumonia (45.5% in demented versus 28.0% in non-demented), cardiovascular disease (46.2% in non-demented versus 31.3% in demented) (31).

Unfortunately, however, many clinicians, radiologists, and others involved in the ante-mortem diagnostic process never have the opportunity to learn of major missed diagnoses among patients who died under their care (16).

In summary, the findings at autopsy can help us improve our diagnostic skills by confirming, clarifying, or correcting the ante-mortem diagnosis (24). Autopsy remains a valuable tool to evaluate the diagnostic and therapeutic process, especially in the geriatric population, because both the atypical presentation of diseases and limitations in diagnostic scope may lead to under-diagnosis of potentially treatable disorders (32).

-Let our ignorance of disease in old age serve as a catalyst for the renaissance of autopsy", says Westendorp (28). Even centenarians should receive an autopsy; their deaths should not be merely attributed to old age or senile debility; the majority of them suffer from chronic co-morbidities even though they are considered to be healthy (33).

Clinicians would be asked to obtain permission for necropsy of deaths over and above those cases in which they are particularly interested (23).

By using autopsy results in teaching situations we can learn from each other's mistakes (24). Therefore, the goal of autopsy is not to uncover clinicians mistakes or judge them but rather to instruct clinicians to learn by their own mistakes. Clinical-pathological necropsy meetings might be very important to prevent MEs. However, autopsy also is not infallible: some diseases cannot be detected by pathologic anatomic examination (e.g. cardiac arrhythmia) and pathologists may err as clinicians do (26).
MITIGATING MEDICAL ERRORS

Diagnostic protocols
Nowadays, Evidence-based Medicine argues that medical decisions should be based on the firm foundations of high-grade scientific evidence, rather than on experience or opinion, and this approach is becoming a cornerstone of patient safety (1). We may battle against misinterpretation by demanding duplicate independent readings (34).

We must also avoid overworking our healthcare staff: we cannot expect a dependable performance from workers who are short of sleep or working excessively long hours. This sort of problem is exacerbated in elderly patient because the clinical conditions of the elderly are complex and impose a great burden of care (1). Placing a limit on working hours is an obvious way to reduce ME (34).

Computerized diagnosis
Computerized systems have many benefits, including fewer errors in data recording and communications, the ready availability of up-to-date information, the sharing of data with colleagues and nurses, easy access to a patient's clinical history for follow-up and subsequent hospitalizations. They facilitate statistical analyses and assessments on the benefit of therapies, and even reduce public health expenditure by cutting down on printed matter and time spent on writing and attempting to read handwritten papers, leaving us more time to listen to our patients (1). When patients are discharged from hospital, we may immediately send a complete documentation of their hospital stay to their general practitioners by e-mail (1).

Medical education
An appropriate approach to ME might be to acknowledge the importance of medical training in shaping the physician's attitude to error. Unfortunately, our medical school graduates are unable to cope with ME because nothing in their training prepares them to deal appropriately with the mistakes they will inevitably make (1). Errors are seldom discussed and it is assumed that competent doctors do not make any. Medical students and residents also show little interest in geriatrics, emphasizing the need for an innovative approach and continuous exposure to geriatric-focused medical education (35).

Many students react with intense emotion to the idea of making mistakes in patient care (14), but no psychological support is available, neither for medical students embarrassed about approaching the subject of their mistakes, nor for doctors whose errors have harmed a patient. We need teaching programs for medical undergraduates that convey a tolerance of ME (1). The whole undergraduate curriculum could be seen as an effort to prevent mistakes in clinical practice, with a view to improving the students' ability to cope with errors (1).

Problem-based learning is a popular teaching method (1); a database can promote learning, and a course on MEs would not only help medical students learn to cope with their future mistakes, but also to reduce their frequency (36). In addition, medical students must be oriented in the care of elderly patients, given the demographic realities of medical practice in the 21st century (35).

The Appendix contains a series of recommendations on how ME rates might be reduced.

CONCLUSION
Clinical diagnosis is not a "perfect" science like mathematics, especially when elderly patients are concerned; diagnosis is more difficult in the elderly, so mistakes are more common. An excessive work load and understaffing of nurses in hospitals also seem to have a role in the mistakes made in geriatrics.
Since errors are inevitable to some degree, strategies to improve medical performance have to be developed; accepting our fallibility and identifying errors are fundamental to such strategies. When the barriers of shame and punishment are removed, doctors, nurses, and pharmacists will be able to improve healthcare, implementing good practices or developing better ones. To achieve this, healthcare organization managers (particularly those concerned with geriatrics) need to consider reducing ME among their top priorities.
In summary, we believe that an appropriate programme on MEs to students, to remove the barriers of shame and punishment, to learn from others' errors and to report ours by detecting autopsies, to accept our fallibility, are the basis for coping with our mistakes and for reducing them.

A reflection for all us
We may think on Leape et al.'s (37) words every time we are at the bedside of a patient: "Errors are not diseases: They are symptoms of diseases". The diseases are the inadequate systems we have create in our health care systems. Like pain or fever, it is only when we investigate and discover the causes that we will succeed in eradicating the symptom.

APPENDIX: Recommendations
- Use modern technologies, evidence-based medicine, and problem-based learning in medical student education
- Teach students to accept responsibility for their mistakes and motivate them to care for elderly patients
- Develop systems for preventing medical errors in hospitals
- Create a national database of errors that can be shared and updated, from which to draw recommendations on the security of the elderly patient and the quality of the healthcare service
- Avoid the use of handwritten prescriptions and paper medical records by using computerized systems
- Communicate with colleagues of other specialties to make joint decisions on therapies, thus avoiding drug interactions, which are very common in elderly patients
- Establish a good link among doctors, nurses and pharmacists, as elderly patients often have co-morbidities
- Establish good communications with relatives and patients, and spend enough time with them to adequately assess symptoms and signs, because this is often very difficult to do in geriatrics
- Obtain a detailed history and perform an accurate physical examination, not "trusting" entirely on laboratory and instrumental test findings
- Be aware of the limitations of the diagnostic methods applied
- Have duplicate independent readings of X-rays, ECGs, angiograms, and histological specimens
- Use error reporting to learn from past errors
- Increase the necropsy rate in geriatrics (including centenarians) to produce a higher rate of confirmation of clinical diagnoses
- Improve the approach to obtaining consent to autopsy from relatives, even if they resist the idea because the patient is elderly
- Create voluntary (non-punishing) error reporting programs (with a view to obtaining reliable data on medical errors)
- Create medical codes for errors
- Involve leaders in the medical profession and healthcare organizations by means of open discussions
- Accept the fact that we are human so we are not infallible (a dose of humility is needed), and that we cannot work "miracles" in the geriatric age group.

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Indirizzo:
Prof. Eminè Meral Inelmen
Clinica Geriatrica-Ospedale Giustinianeo (2°piano)
Via Giustiniani,2
35128 Padova
telef: 049-8218493
fax: 049-8211218
email: eminemeral.inelmen@unipd.it