White Coke Cans and the Importance of Visual Cues in Reducing Medical Errors

I read with some amused interest that many consumers were upset that Coca Cola had updated their traditional red regular Coke can for a holiday themed one complete with white packaging. The new holiday design was felt to be too similar to the diet Coke, which is silver. Although Coke has released festive appearing Coke cans in the past, this design was devoid of significant elements of red which make it stand out from the silver Diet Coke packaging. This year Coke felt a bold design would highlight their association with the World Wild Fund and saving the polar bear.

As a result, Diet Coke drinkers not realizing the switch would find themselves gulping the sugary regular Coke, an absolute no-no.  Outraged, they took their concerns up on the internet. Coke has decided to take the new white Coke can off the market and replace it with the traditional red Coke can sooner than planned.





But what does this have to do with medical errors?

Plenty.

Doctors and nurses often work in a world devoid of visual cues where the stakes are much higher than sipping the wrong type of cola. Ironically, doctors and nurses when they makes these errors, they blame themselves and not the package design for some of the error. Even the public

Case in point?

About four years ago, actor Dennis Quaid's newborn twins nearly died from a drug overdose of the blood thinner heparin while hospitalized at the prestigious Cedars Sinai medical center.  The babies were given the adult dosage of heparin which was 1000 times greater than that for a baby. Their blood essentially was water and coming out of every orifice.

Part of the reason for the error? The packaging of the vials for adult and pediatric heparin is nearly identical.





Do they look identical to you? A busy nurse used to routine perhaps gets a heparin dose which by design looks similar but not exactly the same mistakenly draws up the dose because it looks similar but not difference enough to jostle her conscious memory that there is a problem here. This is part of human nature and using mental shortcuts subconsciously. Looking at it now with your full attention it seems obvious.
 Even the public and health care personnel often attributed the error to the individual rather than the design packaging when reviewing some of the public comments related to the story.

Why is Baxter being sued for the hospital having stupid nurses who can’t read?… Shame on Dennis Quaid and shame on the Cedars Sinai for retaining a moron of a nurse.

As a nurse, the reality is that the NURSE DID NOT READ THE LABEL before admninstering the drug. Nurse are taught to take a minute and look over the drug that are about to give. Is it the right route, the right dose, the right drug and is it the right patient. We are taught to not check one but twice or three times. Besides heparin there are many different drugs pachaged the same way. You would have to change every single drug packaging to prevent errors. The reality is the nurse DID NOT perform the 4 checks she was suppose to! That is not the fault of the pharmaceutical company.

But in an intensive care unit where you normally work everyday and where you never had had an error and you mistakenly draw up a medication 1000 times too potent because the packaging looked similar enough that your brain didn't see a problem? You didn't realize that somehow the high dosed medication made it to your hand.

Kind of the same way many diet Coke drinkers didn't realize a higher calorie content soda reached their hand and in their mouth as they went about their routine daily lives.

Unlike doctors and nurses, however, the public rightly didn't blame themselves. The package design contributed to their error.  It is about time that our health care providers do the same and work on fixing the system we work in rather that often simply concluding it is the fault of the individual.

As for me, I think I'll pick up some white Coke cans for the holidays. They are kind of cute!

Your Medical Mind - Book Review. Best for Patients or Doctors?

I looked forward to reading Dr. Jerome Groopman’s new book, Your Medical Mind: How to Decide What Is Right for You , co-authored with Dr. Pamela Hartzband.  His previous work, How Doctors Think , shaped my thinking as a practicing primary care doctor on the importance of language and the potential pitfalls we make in reaching decisions.  I always recommend my medical students read that book.

Unfortunately, his latest work fell quite short of my expectations.  In it, the authors try to understand and create a framework on how patients reach decisions about their medical care.   In the end, this was a book about human psychology wrapped in the doctor patient relationship.  Nothing particularly earth shattering here.

The real question I had is who is responsible for helping patients avoid these cognitive and psychological errors?  Patients or doctors?

They note how the mindset of patients can be divided into the following categories – “believers and doubters; maximalists and minimalists; a naturalism orientation or a technology orientation.”  Specifically, some patients want maximal treatment and others believe “less is more”.  To avoid cognitive traps, the authors recommend that data be viewed in both positive and negative forms.  Telling a patient that a therapy has side effects for 10 percent of patients is very different than saying 90 percent of patients have no side effects.

Other tips to good decision-making included minimizing emotion before deciding, bringing a friend or family member to an appointment to provide additional eyes and ears, and also getting second opinions.  Finding a doctor who provides “shared medical decision making” might also decrease the chance of making a choice only to regret it later.  In the book, many patients moved beyond decision paralysis upon hearing a story of another patient with a similar illness and predicament.  Specifically, patients realized that instead of focusing on the negative, like the side effects, focusing on the positives and the ability to adapt made all the difference.  There is both power and potential pitfall in hearing other patient’s stories, which may be anecdotal.

Dr. Groopman and Dr. Hartzband noted that patient decision making and autonomy vary depending on circumstance.  Sometimes patients want full control.  Other times they wish to cede it to physicians, hence the reason many want to find the “best” physician.  Surrogates, who act on behalf of patients when incapacitated, are ideally supposed to use “substituted judgment” and choose treatment based on what the patient would have wanted.  Like patients, however, surrogates too will change their mind or relinquish or reclaim autonomy depending on the situation.  As a result, sometimes doctors use the principles of “beneficence”, the principle that physicians should act in the patient’s best interest, and “nonmaleficence”, to do no harm.

Physicians can also unwittingly bias a patient’s decision by recommending a “best” treatment and downplaying others, which could be a better match for the patient’s preference.  Although there is a movement in health care to provide treatment which is evidence based, the authors conjecture that this focus would result in doctors recommending treatment not in preference of a patient.  These seems rather ludicrous as already many current guidelines are not being followed.

The authors conclude that patients are best served if they find doctors who do not superimpose their preferences while at the same time don’t simply rubberstamp what you want.  “A doctor who facilitates but also may challenge your decision process sometimes gives you more.”

Completely agree. Perhaps this book is best suited for doctors.  While the book may be an enlightening read for patients, there isn’t necessarily an easy practical framework which will help them make the right decisions.  

Do Computers Really Come Between Doctors and Patients? Is the Future Here?

One of my favorite movies is Back to the Future starring Michael J. Fox.  I must admit after reading this New York Times piece, titled "When Computers Come Between Doctors and Patients" I have to wonder.

Am I fortunate to be coming from the future?  Because I completely disagree with Dr. Danielle Ofri, again.

I've had the privilege and opportunity to work in a medical group which has deployed the world's largest civilian electronic medical record and have been using it since the spring of 2006.  I don't see the issue quite as much as Dr. Ofri did.  It is possible that she examined patients in her office with a desk rather than an examination room.

If placed and mounted correctly in the exam room, the computer actually is an asset and can improve the doctor patient relationship. It is part of the office visit. The flat screen monitor can be rotated to begin a meaningful dialogue between the patient and I. We review the lab work together as well as the trends. Look at xrays. Who needs anatomy flip charts when I can google any image instantly? Patient friendly information to reinforce our discussion is a click away.

The computer can certainly enhance the doctor patient visit. Like any skill, unless we deliberately practice in getting better, we will simply find the new method awkward and unnatural.

And the same goes for emailing patients securely.  An October 2010 article in Pediatrics found that for a 127 families only 5 emails were generated compared to over 2300 phone calls over an 8 month period.  The data doesn't lie.

The conclusion of the article was that -

Although these patients/families expressed strong interest in e-mailing, secure Web messaging was less convenient than using the phone, too technically cumbersome, lacked a personal touch, and was used only by a handful of patients.

So doctors could conclude that patients really don't want to email their doctor.  What a relief because the majority of patients still do not have the option to do so and doctors don't really want to do it.  (Though there could be compelling business reasons not to offer email to patients even if the doctors were technically savvy enough to offer it).

But yet this earlier press release in July 2010 may cause doctors to pause before returning to paper charts, pens, and phones.  This study found that over a two month period, 35,000 patients generated 556,000 email threads.

So what does this all mean?  As doctors we need to change our mindset and look at these changes as opportunities for the medical field to provide care that is increasingly worry-free, hassle-free, and personalized.

The future is here.  That means embracing the computer.

None of my patients would ever go back.

Neither would I.

Speaking of Back to the Future, I understand a limited supply of Marty McFly's shoes are now available for purchase!  Bids are at $4000!

A Doctor Thanks His Mentor - Steve Jobs

I've been reading A Game Plan for Life: The Power of Mentoring written by famed UCLA basketball coach John Wooden.  Wooden spends half of his book thanking the people who had a powerful influence on his life, coaching, philosophy, and outlook on life.  Important people included his father, coaches, President Abraham Lincoln, and Mother Theresa.

Yes, President Abraham Lincoln and Mother Theresa.

Though clearly he could have never met the former and didn't have the opportunity to meet the latter, Wooden correctly points out that as individuals we can be mentored by the writings, words, and thoughts of people we have never and will likely never meet.

Which seems like the most opportune time to thank one of my mentors, founder and former CEO of Apple, Steve Jobs.

Now, I have never met nor will I ever meet Steve Jobs.  Lest you think I'm a devoted Apple fan, I never bought anything from Apple until the spring of 2010.  Their products though beautifully designed were always too expensive.  I'm just a little too frugal.  I know technology well enough that people mistaken me for actually knowing what to do when a computer freezes or crashes.  Yet, the value proposition was never compelling enough until the release of the first generation iPad.  Then the iPhone 4.  Finally the Macbook Air last Christmas.

No, thanking Steve Jobs isn't about the amazing magical products that have changed my life as well as millions of others.  It's more than that.  What he has mentored me on is vision, perspective, persistence, and leadership.  Nowhere is this more important than the world I operate in, the world of medicine.  Increasingly health care is fragmented, confusing, and frustrating for patients.  As Dr. Atul Gawande noted in his commencement to Harvard Medical School:

Everyone has just a piece of patient care. We’re all specialists now—even primary-care doctors. A structure that prioritizes the independence of all those specialists will have enormous difficulty achieving great care.

We don’t have to look far for evidence. Two million patients pick up infections in American hospitals, most because someone didn’t follow basic antiseptic precautions. Forty per cent of coronary-disease patients and sixty per cent of asthma patients receive incomplete or inappropriate care. And half of major surgical complications are avoidable with existing knowledge. It’s like no one’s in charge—because no one is. The public’s experience is that we have amazing clinicians and technologies but little consistent sense that they come together to provide an actual system of care, from start to finish, for people.

We don't have an actual system of care.  A majority of doctors still use paper charts and prescription pads which can be difficult to access or decipher (doctors have poor penmanship?) and communicate with colleagues via letters, faxes, and phone calls.  In an industry which is information driven, this seems too antiquated to be true.  Hospitals each have their own unique system of care and their is little standardization which means both patients and doctors need to learn new rules with each new hospital.  Patients cannot invest in long term relationships with their doctors because they change jobs, their company or their doctors dropped their previous insurance plan.

What we have is a potpourri of doctors, hospitals, pharmacies, and health insurers cobbled together to form a "health care system".  For a patient, the number of combinations is staggering.  Each experience varies depending on who they see, what insurance coverage they have, and the type of (or lack of) information technology their doctors have.  Many doctors today still bristle at the possibility that they actually need to email their patients and as a result don't offer that as a way of communication or education.

In the end, what patients and doctors really want sits at the intersection of humanity and technology.  Patients want doctors who know them as individuals, use medical technology thoughtfully, and a system that is highly reliable, safe, and focused on them to stay well or get them better.  Doctors want patients who are partners in their care, technology that enables them to get the accurate information they need real-time, and a system that is streamlined to allow doctors to be healers.

In other words, we need a better health care system for both parties.

As a practicing primary care doctor, his words inspire me to help work towards creating a system which "simply works" for both doctors and patients.  Some of the most important quotes that has shaped my thinking include:

“Innovation has nothing to do with how many R&D dollars you have. When Apple came up with the Mac, IBM was spending at least 100 times more on R&D. It’s not about money. It’s about the people you have, how you’re led, and how much you get it.”
— Fortune, Nov. 9, 1998

“It’s really hard to design products by focus groups. A lot of times, people don’t know what they want until you show it to them.”
— BusinessWeek, May 25 1998

“It comes from saying no to 1,000 things to make sure we don’t get on the wrong track or try to do too much.”
— BusinessWeek Online, Oct. 12, 2004

“Do you want to spend the rest of your life selling sugared water or do you want a chance to change the world?”
— The line he used to lure John Sculley as Apple’s CEO, according to Odyssey: Pepsi to Apple, by John Sculley and John Byrne

"So you can't go out and ask people, you know, what the next big [thing.] There's a great quote by Henry Ford, right? He said, 'If I'd have asked my customers what they wanted, they would have told me "A faster horse." ' " -- CNN / Money

"My job is to not be easy on people. My job is to make them better. My job is to pull things together from different parts of the company and clear the ways and get the resources for the key projects. And to take these great people we have and to push them and make them even better, coming up with more aggressive visions of how it could be." -- CNN / Money

"Your time is limited, so don't waste it living someone else's life. Don't be trapped by dogma — which is living with the results of other people's thinking. Don't let the noise of others' opinions drown out your own inner voice. And most important, have the courage to follow your heart and intuition. They somehow already know what you truly want to become. Everything else is secondary." -- Stanford 2005 commencement address

Many of my blog posts have reflected on whether health care can indeed be better than it currently exists much the same way Jobs has redefined how we as a society communicate, relate, receive, and create content.

Does America Want Apple or Android for Health Care? 

What Steve Jobs and iPhone 4 Antennagate can Teach Doctors and Patients

Why Healthcare Needs to be More Like Apple and Less Like Windows / Intel 

I as a doctor I'm incredibly sorry that medicine has not yet evolved to the point that a cure exists for the rare type of cancer Jobs.  I'm sorry that he is so ill at an incredibly young age, in his mid 50s, when many people begin to contribute even more to society with all of the knowledge and experience they've acquired.  The future might be a little less bright without Jobs leading his team at Apple on creating products and experiences none of us truly knew existed until he showed them to us.

And yet, I wanted to thank him for his mentoring.  Clearly though the outpouring of comments and support across the web, Steve Jobs has had a profound influence in many of our lives.  In most cases, it wasn't even about the products.

It was simply a way of living and viewing life.

I look forward to learning one last time from my mentor this fall with the release of his book titled Steve Jobs. 

My thoughts are with him, his family, and the people at Apple who continue to innovate and challenge themselves so the rest of us benefit.