Negligent People or a Bad System Leading to Surgical Errors?
A woman has the wrong side of her brain operated on. The headline features the hospital's name and the surgeon's name. It seems the “name, blame, and shame” process has begun.
In complex systems, like healthcare, is it overly simplistic to blame the surgeon? Probably. One could say the hospital system owns responsibility for the overall process and outcomes… but surgeons are often not employed by the health system, which complicates things.
Are we focused on learning and improvement, or blame and punishment?
From media accounts, what happened to the patient, Regina Turner?
A St. Ann woman went in for surgery on the left side of her brain, but the procedure was mistakenly performed on the right, and now the hospital is facing a lawsuit.
This definitely falls in the category of a so-called “never event” – a wrong-side/wrong-site surgery. They are called never events because they SHOULD never happen… but they do happen, sadly. If we had good processes and systems, errors like this would never happen.
So, when they do happen, do we shake our heads and say, “ah, human error… we're human, so we can't expect perfection… errors will happen.” Or, do we punish that “bad apple” so that individual can't make the same error again? Would we strip the surgeon of their license? Throw them in jail? Either of those actions would probably result in a huge loss to society, removing a skilled surgeon who was involved in one mistake.
Writing “involved in” might sound like passive voice abuse… but the surgeon does not work alone. It seems overly simplistic to automatically attribute an error to a single person working in a team.
From this case, the news reports say:
- There was a surgical site marking (a good practice)
- The marking was done on the WRONG SIDE (so we'd then ask why this occurred… and how could we error proof the system to ensure this doesn't happen again).
I thought the best practice was for the surgeon to personally mark the site. The surgeon should be familiar with the patient and the case, as to know whether they are supposed to operate on the left or right side of Regina Turner's head. It's easy to see where errors are more likely to occur if the surgeon is not involved, if the marking is done by a nurse.
I've thought it seems smart to also mark “NO” or “WRONG SIDE” in addition to marking the surgical site. Markings sometimes get wiped away or washed off during surgical prep (which gives us another “why?” to ask and another countermeasure to find).
Turner's attorney said:
According to the Journal of Neurosurgery, Wolff pointed out, there have been 35 documented cases of wrong-side craniotomies ever in the U.S.
If the hospital and surgeon have a standard process that says the surgeon IS supposed to mark the site, and they did not, we'd want to ask “why?” The surgeon might have been under time pressure. But, surgeons and physicians have a lot of power and relatively high levels of autonomy, so I'm less forgiving of a surgeon who feels pressured into rushing or cutting corners. I'm more forgiving of a nurse or somebody lower in the traditional hierarchy.
In the Turner case:
“Sometimes the x-rays can be flipped,” he explained. “Sometimes the doctor doesn't look at the medical records. Sometimes the surgery comes off late and everybody's in a rush. Sometimes, if a doctor has a whole lot of surgeries, let's say he's got eight knees to do that day, and he's got four right knees and four left knees, and the first knee cancels and they start moving everybody up, the wrong knee goes in the wrong room.”
Some of the errors:
- X-ray was flipped — why? Can this be prevented through process or technology?
- Sometimes MD doesn't look at the medical records — why?
What's the right balance in “holding the MD accountable” and recognizing they work in a system?
- Sometimes things run behind schedule and “everybody's in a rush” — why are things behind schedule? why is everybody in a rush?
- If a patient cancels, is there a good process to ensure that everything else stays in sync to prevent wrong-patient mixups??
Whose responsibility is it to make sure people don't rush? I had outpatient surgery a few years ago and things were running at least three hours behind schedule. The surgeon apologized, but I agreed that it's better to do quality work on all the other patients, as I didn't want the surgeon rushing through my case either.
If the “rush” is driven by the behavior of an individual surgeon, we might hold them more personally accountable.
But, what if the “rush” was driven by something more complicated? Maybe the department had targets or incentives (or punishments) that resulted from on-time case starts or some other metric? What if the scheduling template wasn't realistic and cases weren't scheduled with enough time? What if the surgeon had been yelled at previously for taking too long in the O.R.? Does management ever get held accountable for their behavior that might cause people to rush and cut corners?
This could be far more complex than “bad surgeon.”
The patient's attorney said:
“I hope everybody who is operating on people pays a lot more attention because more healthcare providers are really, really good,” Wolff added.
I agree that healthcare providers are generally outstanding people – smart, caring, motivated, and hard working. I disagree that asking people to “pay a lot more attention” is a good root cause countermeasure. We need to design better systems, not just say “be more careful” with warning signs and slogans.
As I blogged about yesterday, the patient is a victim here, but the surgeon and the entire surgical team might be “second victims,” as well.
The system issued this statement:
“St. Louis SSM Health Care and SSM St. Clare Health Center sincerely apologize for the wrong-site surgery in our operating room. This was a breakdown in our procedures, and it absolutely should not have happened. We apologized to the patient and continue to work with the patient and family to resolve this issue with fairness and compassion.
“We immediately began an investigation. We have since taken steps to be even more vigilant to prevent such an error from happening again.
“Medicine is a human endeavor, and sadly, people and systems are not perfect. When an error occurs, it is tragic for the patient, their loved ones and the medical team.
“Our SSM St. Clare Health Center team is made up of dedicated health care professionals who are devastated. We can and will do better. That is our commitment to the community.”
I hope the system understands why there was a “breakdown in procedures” so it can be prevented in the future. I hope those steps include process improvement and not just greater “vigilance.” Dedicated, vigilant professionals are a good start – but not wholly sufficient.
We can and must do better. What has your hospital done to ensure that wrong-side / wrong-site / wrong-patient surgeries cannot occur? How does your words about commitment to your community manifest in process improvement actions?
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