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Errors in surgery are individual, not systemic

          An article of mine has been accepted by Skeptic magazine and will be published in the next few months. It is entitled: Still Unsafe: Why the American Medical Establishment Cannot Reduce Medical Errors. One of the important themes it will discuss is that systems errors are uncommon. These are errors in the delivery systems of health care, such as failing to give pre-operative antibiotics, an aspirin in the midst of a heart attack or operating on the wrong part of the body. Although the Harvard Medical Practices Studies showed that only 6% of harmful medical mistakes were of this type, error reduction efforts in this country's hospitals are based almost exclusively on preventing them.
          A paper published in 2008 in the journal Surgery and written by Dr. Peter Fabri makes the point of the rarity of systems errors as applied to surgery of several types. After an extensive review of the surgical results of almost 10,000 patients in one year at the University of South Florida School of Medicine's department of surgery, Dr. Fabri found that system errors occurred only 2% of the time. The vast majority of harms to patients who underwent surgery could be traced to the mistakes of individual surgeons. This was the same conclusion that I had reached after reviewing the findings of the Harvard Medical Practice Studies which covered all fields of medicine.
          The other major type of harmful error in the Harvard Medical Practice Studies was the diagnostic error. Recent reviews of diagnostic errors and their prevention have concluded that systems fixes that have been relied on for almost everything in the field of improving patient safety since 1999 are unlikely to be of much help. The problem seems to be in the cognitive processes and clinical skills used in the initial diagnostic doctor patient interaction. Electronic health records do not lend themselves to arriving at the proper diagnosis. Check lists are similarly deemed unhelpful by experts in diagnostic error prevention. Both are systems approaches. Everything has to be rethought because what causes the correct diagnosis to come to mind is unknown. 
          While the aims of systems methods are laudable in themselves, the use of those methods has resulted in  a lost decade and a half of trying to save well over a hundred thousand people who die as a result of preventable medical errors.

 

15 Comments to Errors in surgery are individual, not systemic:

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Jackson on Wednesday, November 27, 2013 9:21 AM
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Toby on Sunday, December 08, 2013 11:55 PM
I've been working for years to improve the quality of care in the hospitals I attend. I've swallowed the IOM's coolaid, but long suspected what you discuss in your article in Skeptic. Is there a way for me to get copies of this article to bring to the quality officers & the med exec committees? I think it's interesting that I've heard both Leape & Berwick lecture on he virtues of the systems approach, and yet they've intimated to you that they realize the truth about the 2%.
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Philip Levitt, M.D. on Saturday, December 14, 2013 5:04 PM
It feels great not to be alone. Lucian Leape told me several years ago that doctors who feel that there should be greater accountability in the profession are rare. He was disappointed that an article he had written about cultivating problem physicians back into the fold of the competent had gotten no response. That, I speculate, may be why he was "blown away" (in his words), by systems and the whole systems thing began. The Skeptic article is available on Skeptic.com, then click on the magazine button. You do have to pay for it, $5.


George on Saturday, December 14, 2013 11:02 AM
This article struck a nerve. As a clinical systems (computer) analyst, I was asked to use our computer documentation to implement just about all the “system approach” ideas suggested such as antibiotics prior to surgery, JCAHO “core measures” such as ASA for MI diagnoses, antibiotics within 4 hrs of pneumonia Dx, and a system to guide the nurse documenting central line assessments etc. When hospitals were compared, ours ranked quite high for items such as offering pneumoccal and flu vaccines and smoking cessation counseling (virtually 100%). However, when I asked (and I did) if we could measure any outcomes for improvement of patient care (decreased infection rate, re-admissions within 30 days etc) we either did not measure or saw no improvement. We did look good to review agencies. I wish I had the article in Skeptic or had read a similar article that I could have used to suggest a better use of our time. You are 100% correct that only a few doctors cause most of the bad outcomes and we need to get rid of them. But how? The article touched on some of the problems. We had 2 such physicians, one a surgeon who had such bad outcomes, he lasted only a couple of months. I wish I knew how he was evaluated for employment. The second lasted almost 2 years. My primary physician said no one would refer patients to him – I suspect that is why he was fired. I knew a nurse who worked for him who told me she had to leave because he lied when he documented procedures and she would not be part of that. She moved to another hospital. I asked her why she did not report this – “Who would believe me?” she asked. The administration had to wait until physicians saw bad outcomes – many months delay. We need to involve other health professionals. That nurse should have had a way to report her suspicions. Nurses work with physicians and when a good working relationship is established, many mistakes can be caught. This is an excellent way to reduce errors. We were also asked to implement “Medication Reconciliation”. The idea was to have physicians review all medications as the patient was admitted, transferred to another level of care, and on discharge. Physician compliance was often difficult to obtain due to time constraints. So, while the physician is still responsible, we put the burden on the nurses if it was obvious the physician was not going to be available. The process was nurses reviewed meds and contacted physicians with questions. I heard a lot of complaints that “this was not their job” but, after they reviewed a number of discharge medication lists, they all agreed that it needed to be done. In retrospect it was difficult for me to see how patients could have been discharged on so many incompatible meds. 1. So the point is well taken that incompetent physicians need to be fired ASAP. I would add that part of the process should be a safe way that any health professional could report concerns that might be addressed. (We tried such an approach but not for questioning physician competency). 2. Fostering good working relationships between physicians and other health professionals. 3. System approaches can be useful as the article pointed out for central line infections but also for targeted problems such as medication reconciliation. Hopefully when I follow this blog, I will see some comments and more suggestions to reduce preventable bad outcomes.
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Philip Levitt, M.D. on Saturday, December 14, 2013 5:24 PM
Yours is a remarkable comment. Thank you. Unfortunately, systems has some nasty progeny out there. I'm thinking mainly of the Leapfrog rating of hospitals which is based on systems markers like wound separations and the old standbys of aspirin and beta blockers for myocardial infarction. It misses what Fabri found in ten thousand surgical cases, the the most common serious mistakes are made by doctors and they are of the non-systems types. So if you have a great institution like UCLA with great attendings and they only take the cream of the crop onto their house staff, and they get an F from Leapfrog, you have to wonder. (I have no affiliation with UCLA but an internship there was one of the most sought after in the country when I was a medical student). Nurses are the serfs in a feudal system. They do not take on knights(doctors)or the the barons and earls (administrators). There are simulations of difficult emergency diagnostic situations that some residency programs have begun to use that seem to improve performance. The same with better ways of signing off physician to physician. Animal surgery in the lab is another way of increasing resident's skills to help them become able surgeons sooner. There's just so much you can do with a bottle of aspirin, a checklist or a time out. A lot of systems tactics involve areas where there already had been a good deal of compliance and errors were rare. An example is wrong side surgery which makes big headlines but is dwarfed in overall importance statistically by other kinds of surgical errors.


George on Sunday, December 22, 2013 3:11 PM
our last remarks were to the point. My take away was that historically to reduce medical errors we have tended to focus on areas of high profile and system approaches (leapfrog et al) rather than take a more comprehensive approach focusing on areas where w can get the biggest bang for the buck. Wrong sided surgery makes headlines and people talk about this for years and we use lots of resources solving this type of problem rather than solutions that would be of greater benefit. Your comments in the blog about system improvements for simulation of emergency situations and better sign off between physicians are examples where a system approach is useful. There is a gray area where physicians are not as good as they should be but are not in the 2% incompetent range. So: 2 problems that would do more to prevent serious medical areas than the systems approaches. Find some way(including "threats"to get hospitals and individuals to report serious problems to hospital boards and less threatening state boards. The second approach is to improve specific individual physicians and groups not in the 2%. There is a relatively new specialty for physicians: Hospitalist. A Hospitalist sees only hospitalized patients – usually on shifts where Attendings are not “in house”. These Hospitalists do not have a specific residency program but graduate from (usually) a medical residency. They are all excellent at their primary function – allowing the attending to get a good nights sleep. However, they are not trained as intensivists and I doubt many have been beneficiaries of a program using simulation of emergency situations. Here is what happens in my experience: Many nurses have had lots of experience executing orders from Attendings and specialists and so have expectations of certain actions for given situations. Hospitalists often react to situations with orders that the nurse deems inappropriate. Since this is not a residency program, there is no senior resident to call. So the nurse calls the appropriate specialist from an on call list or the attending if there is not an appropriate consult. The issue is then resolved. This makes nurses uncomfortable. Using the feudal analogy, the serf has to go over the knight's head to the Earl. This could have bad consequences for the surf so he/she consults the baron (nursing supervisor) as well as fellow serfs before making the call. There should be a training program for Hospitalists. This might be nothing more than having new hospitalists follow appropriate physicians – especially whoever functions as intensivists in the hospital. The primary way to reduce medical errors is to remove incompetents but there are many aspect of current medical practice that need to be addressed. We need to focus on physicians practicing a levels below their abilities as well as improving other health care professionals. Some Physicians Assistants, for example, are operating above their pay grade by running small emergency rooms with a Physician only as a nominal backup. Such programs need a lot of inspection. (But that is another story).
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Philip Levitt, M.D. on Wednesday, December 25, 2013 1:07 PM
The other 98% commit errors at roughly 1/50 the rate of the 2%. They are not problem doctors. Sutton's law applies here, go where the money is. And the surest, quickest way to reduce unnecessary deaths, is in my opinion, of course, to get rid of the 2%. I've sat down and spoken to both kinds of doctors. The 2% lack insight. They can look at an image that shows conclusively that they screwed up and not see what everyone else sees. You have to see it yourself to believe it. The ones in the 98% have already figured out what they have done wrong and beaten themselves up repeatedly before they get the letter from the quality assurance committee. Lots of hospitals screen adverse events for physician culpability and then their colleagues decide whether it merits a letter of inquiry. Usually that alone is enough to change the practice patterns of a conscientious physician, even if at times he doesn't fully agree with the committee's appraisal.
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J Paul Curry, MD on Monday, May 05, 2014 7:24 PM
Dear Dr. Levitt I am a 69yo retired anesthesiologist and ex emergency medicine physician who is still very active in patient safety issues on a national scale. I read your March 15 Op-Ed piece in the LA Times, "When Medical Errors Kill" with great interest. I, too, have a background in physician leadership, having served a 6 year commitment as a Medical Staff Officer that included being Chief of Staff to 1500 private practice physicians in Newport Beach, CA. I believe there is a lot of truth to your well referenced article, but also believe it doesn't tell the whole story. I would love to spend a few minutes of your time in a phone conversation, sharing mutual insights that include on my end a disappointing discovery regarding CMS and a newly vetted quality measure that will cost lives due to the tainted processes used to create it. It seems no matter where one dives into healthcare, vast incompetence will be found, process and people centered alike. Best regards JPC
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First Aid Course on Sunday, December 21, 2014 3:20 PM
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http://www.aussiessay.net/ on Tuesday, July 11, 2017 5:11 AM
Many people face different issues in their surgeries. So, this is somewhat symmetrical error too. But, mostly this thing happens because of human negligence. Because they don’t like to give proper attention to these things too much.
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