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| Artwork by Marion Fayolle at the New York Times |
My last word:
As a general matter, if you can characterize an error or near miss by saying, “It could have happened to anybody,” that is a pretty good indication that it reflects a systemic, rather than a personal, problem.
4 comments:
The end to the NY post is phenomenal and really makes your point. I agree in looking for a balance and punish only blatant cases of negligence.
The right/left ankle case puzzles me. I am a surgeon and I offer my view of the issue. I am as busy as anybody elese, Yet, before every case, in the morning or the afternoon prior to the procedure I review my notes to see if my intended work up is complete. For cases that involve laterality, I check the day of the operation, so I won't forget the laterality. Then I always go to the preop area, introduce myself to the patient and family, chat with them for a few minutes and confirm with the patient the laterality and changes in his/her condition. This is my practice, I make time for this routine, deliberately. If some don't, then they should be punished. There is no excuse to check laterality beforehand in person. This is my opinion and many can agree or disagree.
However, in the federal system (VA) I observed a switch from individual to system accountability, as you propose. There are three (I mean 3) verification processes (in preop, in the OR and again in the OR) in which the surgeon needs to be present. Also, In the VA system, a patient cannot roll out into the OR if the surgeon does not state that he has seen the patient and confirm the procedure and indication. A great example of process improvement. Still, I categorize lack of familiarity with a patient as negligence regardless of system processes built around it to minimize the variability of individual surgeons' practices.
As a former Chief of Staff of a major teaching hospital, one of the things that challenged us were physicians who had erred but argued that peer review was wrong and they were right. On the couple of occasions when a bright physician readily acknowledged an error, our job was dramatically simpler. Those who acknowledged an error also had typically already set in place a strategy to prevent the error, again. Those who fought the error call-out were sadly committed to keeping bad processes in place.
An apology to a patient is one piece of error management. At least as important is to have a mindset to identify error prone processes and fix them before major error creates problems. Likewise, when errors occur, a thorough look at process improvement is essential.
At one point, with the habit of reading all of the adverse outcomes reports every month, I noted a recurring type of error that was sometimes fatal. As we set out published ways to avoid the error and put a work group together, that error type disappeared. When policy was later passed by the Medical Executive Cte, it had already taken hold.
In my own practice, part of our daily challenge is to identify errors and address them, fully believing that a culture that does not seek to scrub out errors is one that invites patient injury. Many, many health care environments have copied the industrial mantra that each should be empowered to point out thinks that need correction. In our complex world, true caring is to look for every opportunity to improve.
As a former chief of staff of a major teaching hospital, one of the fascinating things was the differences among physicians whose peers criticized them in peer review cases. Those who acknowledged the errors had already set in motion steps to prevent recurrences. Those who fought the allegations of error seemed to committed to error prone processes.
Intriguing as well is that the process of setting up processes that are less error prone, involving as many as practice the area of concern often solves the error rate before a new policy becomes official. While some may fight the changes feeling accused at first, as the process continues with clear evidence of what would constitute process improvement, the practice pattern changes reflecting the emerging policy.
On the issue of laterality of surgery, the commentator, "anonymous" above is absolutely correct. It seems that surgeons who are less diligent about checking laterality are almost exclusively the ones who do wrong-site surgery. I follow a pattern of checking my notes at a preop visit, assuring with the patient that laterality is correct and then check again in the preop holding area where the site gets marked before the patient is sedated and again twice in surgery.
Space limitations in the Times prohibited a full discussion of this case. As often occurs, there were a number of factors that caused "the holes in the Swiss cheese to line up."
This was the first such wrong-site case for this surgeon in decades of operations. He is an excellent and thoughtful person and was devastated that he had caused harm to a patient. (A sign of his professional standards is that he actually informed his other patients about his error and offered to refer them to other doctors if they were worried about his likely performance for them. I know of none who chose to do that, and I would not hesitate to go to him for myself.)
As we looked into the case afterwards, we found that there were many systemic factors that came into play--that, had they been corrected previously, could have prevented his momentary lapse from having the result it did.
I would assert that even the most diligent surgeon needs a fully engaged crew around him to help him from making a mistake.
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