The One Percent Solution - September 29, 2004

Over the summer, I received an e-mail from a friend of mine who has a successful construction business. He and his family have been patients at The Johns Hopkins Hospital and are great fans of what we do here. His e-mail recounted the unfortunate situation of the 3 year-old son of one of his subcontractors—a tree removal specialist—who was being treated for leukemia at the Hospital.  

The boy was scheduled for bone marrow transplantation, and protocol required prior treatment with a special serum to prevent rejection. The child received the wrong batch of serum and also, in spite of a nurse’s warning, was given an adult dose rather than a pediatric dose. Fortunately, the child survived the massive overdose and the wrong type of serum.

The father, obviously quite distraught, spoke with the attending physician, who explained that medication errors do occur at Johns Hopkins, and that, in fact, “we try to keep the error rate down to about 1 percent.” Hearing this, the father of the child went ballistic. “If I had a 1 percent error rate in my business, I would kill or maim one of my employees every month!” Recounting this incident to my friend, the father said, “I took my precious son to Johns Hopkins. They are supposed to be the best in the world. Where can I take him if not Hopkins?”

You might think this was an isolated incident involving an uninformed Hopkins doctor. But I think this type of thinking is endemic to our Hospital. A few months earlier, while I was making executive rounds, I met with a representative from pharmacy to discuss missing medications. I asked her what level of missing medications she was striving for. Her answer: “4 percent.” This time, I went ballistic. “How can you tolerate a 4 percent missing medication rate? “I retorted? She said the 4 percent level was a realistic goal, since in many situations the missing medication was not the fault of the pharmacy; rather it might be misplaced on the ward, or lost in transit, etc. “Does the patient care,” I asked, “whose fault it is when the proper medication fails to show up and be administered at the bedside?”

It appears that we continue to have a disconnect between the public’s expectation of our level of performance and what we ourselves are willing to accept. When we all can agree that zero errors is an achievable goal, and when we each take full responsibility for patient safety, we shall actually make The Johns Hopkins Hospital the best and safest hospital in the world.