Preventing medical errors is a subject that is belatedly attracting a lot of attention. The way in which hospitals prevent errors and manage them after they happen is undergoing a major transformation. (See the links below to my prior posts on medial errors.)
The traditional plan for error prevention in medicine can be summarized as “we should all be more careful”. Physician autonomy and diversity of practice styles were thought to be sacrosanct and it was thought that errors could be minimized if physicians were simply more cautious. But any engineer will tell you that humans can only be so careful and that any system that depends on human memory and attention to prevent errors will fail frequently. Medicine is finally learning from aviation that safety depends on multiple redundant systems to prevent mishap and that simple strategies such as checklists and flowcharts can cut errors dramatically.
This week’s New England Journal of Medicine devotes three articles to this issue. The first article is a Case Record, which is typically a puzzling case in which a mysterious disease is diagnosed by the brainy doctors at Mass General. This week the case is not mysterious. It’s a brutally honest story of a surgeon who performed the wrong surgery on a woman’s left hand – a carpal tunnel release instead of a trigger finger release.
The discussion of the case reads like a suspense thriller. The reader knows that something bad is going to happen and multiple plot twists make the bad outcome more likely. The surgeons were running behind schedule, necessitating some changes to the operating room team. That meant that the team that went over the details of the surgery with the patient before the surgery would not be the same as the team in the operating room. The surgery prior to the one in question was a carpal tunnel release. That patient became upset and agitated in the recovery room. The surgeon spent time consoling her, but found the encounter quite anxiety-provoking. He promised himself that the next surgery would be “the best carpal tunnel release that I have ever performed.”
In the operating room, standard protocol calls for a “time out” in which the critical pieces of information are reviewed – the identity of the patient, the type of procedure, the specific site – by the entire team prior to the first incision. The patient did not speak English and the surgeon (but not the rest of the team) was able to communicate to her in Spanish. He had a brief discussion with her in Spanish before the surgery, which the anesthesiologist and the nurse mistook to be the formal “time out” but wasn’t. A time out was never done. Clearly, multiple lapses in procedure contributed to this error.
Immediately after the incorrect surgery, the surgeon realized his mistake, returned to the recovery room and disclosed the error to the patient. He apologized and asked permission to perform the correct procedure which was done immediately thereafter.
The consequences of this case were relatively benign – the patient has to heal from an unnecessary surgery to her wrist. Obviously other medical errors lead to more catastrophic losses.
The second article was a study in multiple hospitals in the Netherlands. The study involved the adoption of a detailed checklist that covered all steps in surgical care from preoperative preparation to postoperative care. The number of surgical complications and errors declined dramatically after the adoption of this checklist. Surprisingly, complications even decreased in aspects of surgical care not mentioned in the checklists, suggesting that the checklist may have had some unforeseen benefits such as a less distracting operating room or less harried surgeons.
The final article was an editorial that reminded us that – compared to industries with mature safety cultures like aviation – medical safety still has a long way to go.
ABC News article: Doctor Gives Public Mea Culpa after Surgical Mistake
Case Records of the Massachusetts General Hospital: A 65-Year-Old Woman with an Incorrect Operation on the Left Hand
New England Journal of Medicine article: Effect of a Comprehensive Surgical Safety System on Patient Outcomes
New England Journal of Medicine editorial: Strategies for Improving Surgical Quality — Checklists and Beyond
My post in August about changing how medical errors are handled: Admitting our Mistakes
My post in 2009 about adopting a culture of safety in healthcare: Got Safety?
My post in 2007 about teaching physicians to disclose errors: Learning to Say “I’m Sorry”
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