Preventing Brain Surgery Errors… Not Exactly Rocket Science
Thanks to those of you who sent me the link to this Washington Post article called “The Pain of Wrong Site Surgery.” The piece highlights how the patient safety battle has not yet been won and “some researchers and patient safety experts say the problem of wrong-site surgery has not improved and may be getting worse.” A recent Health Affairs study found that medical errors affected one-third of hospital patients.
Why is it so hard to use checklists in the right culture (a “just culture,” perhaps) that makes so-called “never events,” such as wrong-site surgeries never happen? People might say “it's not rocket science” to follow basic procedural steps.
“I'd argue that this really is rocket science,” said [Dr.] Mark Chassin, a former New York state health commissioner and since 2008 president of the Joint Commission.
But is it?
Some of the other quoted doctors express frustration that medical errors haven't been eliminated, including one who differs with Dr. Chassin:
“This is not quite ‘Dick and Jane,' but it's pretty close,” surgeon Dennis O'Leary declared in a 2004 interview about the “universal protocol” to prevent wrong-site surgery. These rules require preoperative verification of important details, marking of the surgical site and a timeout to confirm everything just before the procedure starts.
Dr. O'Leary added this is “very simple stuff.”
Dr. Peter Pronovost, author of the excellent book Safe Patients, Smart Hospitals: How One Doctor's Checklist Can Help Us Change Health Care from the Inside Out, says:
“It's disheartening that we haven't moved the needle on this,” said Peter Pronovost, a prominent safety expert and medical director of the Johns Hopkins Center for Innovation in Quality Patient Care. “I think we made national policy with a relatively superficial understanding of the problem.” Pronovost suggests that doctors' lip service to the rules, which he calls “ritualized compliance,” may be a key factor. Studies of wrong-site errors have consistently revealed a failure by physicians to participate in a timeout.
As I've been trying to help teach for years – it's not the checklist itself that's important, it's how it's used – it's about having the right culture and accountability in place. Having a laminated checklist does no good if a surgeon won't follow it, if they're pressured for time or productivity and feel that they can't use it, or if nurses, techs, and other staff members can't speak up when they see somebody ignoring the timeout, checklist, or “universal protocol,” whatever you'd like to call it. The checklist can't help patients if medical professionals aren't using the checklist.
“Universal protocol” certainly was an aspirational statement. It seems to not be reality today, the “universal” aspect.
Another comment from the article:
“It's very frustrating,” said surgeon John Clarke, clinical director of the Pennsylvania Patient Safety Authority. “If you can't solve the wrong-site-surgery problem, what can you solve?”
Why is this so hard?
Dr. Chassin said:
Preventing wrong-site surgery also “turns out to be more complicated to eradicate than anybody thought,” he said, because it involves changing the culture of hospitals and getting doctors â€” who typically prize their autonomy, resist checklists and underestimate their propensity for error â€” to follow standardized procedures and work in teams.
Changing the culture requires leadership and it might be challenging, but it's not rocket science. It's psychology, if anything.
My friend Naida Grunden sent me another story, “Nudging Doctors In Intensive Care Unit Reduces Deaths.”
From that Northwestern research:
A new Northwestern Medicine study shows the attending physician in the intensive care unit could use a copilot, too. The mortality rate plummeted 50 percent when the attending physician in the intensive care unit had a checklist – a fairly new concept in medicine — and a trusted person prompting him to address issues on the checklist if they were being overlooked. Simply using a checklist alone did not produce an improvement in mortality.
It's not the checklist, it's how you use it. I'd argue this is NOT rocket science. Again, it's complicated to think about WHO is going to prompt the surgeon and what the implications are of power and hierarchy in the O.R. One reason aviation safety has been so improved, through their more effective use of checklists is the cultural shift to reduce hierarchies in the cockpit so that the first officer feels safer speaking up to the captain if they think there is a problem.
This is all a pretty meaty and serious topic. Please read the entire WashPo piece (there are multiple pages if you don't have it in print-ready mode). Please share your thoughts and reactions here in the comments.
To try to go into the weekend on somewhat of a light note, here is a video that was first shared with me a few weeks ago when I was doing a Lean healthcare workshop. I hope you have access to the video or go watch it over the weekend. It's a good laugh…. an arrogant brain surgeon introducing himself at a party to people. The punch line is pretty obvious, but it's still brilliantly delivered at the end.
Have a good weekend.