Some things should never happen in healthcare, like operating on the wrong place or providing the wrong medication or dosage. But such things happen, sadly.
In a study of one insurer’s malpractice claims stemming from 68 wrong-site surgery claims between 2013-2020, 46% of patients required a second surgery, 10% experienced mobility dysfunction, and 9% had a worsened injury. Even worse, 15% died or totally lost function, about equally split.
These mistakes should never have occurred. Since 2004, The Joint Commission (which accredits US healthcare organizations) has mandated a Universal Protocol for surgery. The protocol requires a pre-incision verification process, the surgeon marking the incision site on the body, and a surgical team time-out immediately before the incision so that any team member can stop the surgery. Yet between 2018 and 2022, The Joint Commission received 525 reports of wrong surgery. It’s a likely undercount as reporting of “sentinel events” is strongly encouraged but not required. Wrong surgery includes wrong site, patient, procedure, or implant, but mostly the wrong site. (Sentinel events are unexpected occurrences involving death or serious physical or psychological injury, or the near-miss risk of that happening.)
What then went wrong in the cases from the 2013-2020 study? In 84% of the cases, the team did not follow the operating room protocol/policy. In a shocking 41% of the cases, the medical record was not read.
You might argue that the error rate is low. There are about 15 million surgeries each year in the US after all. That is a lame excuse. In 2022 US airlines carried 853 million passengers with no pilot-error deaths.
Avoidable errors in healthcare settings are, in fact, far more common than the public realizes. A medical record review of the Medicare database showed that 25% of patients had adverse outcomes in 2018, with 46% of them preventable, no better than in 2010. Sadly, hospitals identified only 14% of the errors as errors for learning purposes.
What can we do?
The aviation industry has driven adverse safety events to near zero. Chris Hart is the former Chairman of the National Transportation Safety Board, a pilot, and former Deputy Director for air traffic safety oversight at the Federal Aviation Authority. He suggests we look at system-wide changes versus individual practitioners to reduce avoidable harm. He advocates:
- Address threat and error management through advanced design. For example, we could mandate that pharmacists identify drug interactions before any prescription is filled.
- Build human factors into workflow design and equipment. Anesthesiologists reduced avoidable errors by mandating oxygen monitors on ventilation lines. The alarms warn of potentially dangerous gas combinations being delivered to the patient.
- Advance collaboration. Create cultures of safety which slice away hierarchies thus encouraging open conversation.
- Design processes to avoid single point failures. The Joint Commission surgical process takes the decision to operate away from the surgeon alone and gives it to the team.
- Engage in collective learning from errors and omissions, where, for example, a surgical team openly discusses the problems with a procedure that was performed. This would likely be the most problematic change in healthcare owing to malpractice concerns.
In line with this advice, the Patient Safety Movement Foundation recommends a national private-public board to measure patient harm, investigate it scientifically, and advance human-factor-based solutions to reduce it.
The Centers for Medicare and Medicaid Services (CMS) has multiple initiatives for reducing avoidable harm. For example, it is advancing value-based payments that penalizes healthcare organizations for errors. Commercial insurers are laggards in the move to value-based payments, sadly. A commercially insured patient readmitted to a hospital due to an avoidable error generates more net income for the hospital.
The forces that will increase the probability of harm are many. Healthcare organizations are under ever-increasing financial and productivity pressures as well as staffing shortages. We’ll need to fight back with every tool at our disposal.
What should you do as a patient? Here are just a few suggestions:
- Be proactive in checking potential failure points prior to any operation. For example, ask if the surgical team knows your blood type and if the type is correct. (A friend who is a transplant survivor discovered in a recent procedure the team had the wrong blood type in the record.)
- If undergoing advanced scanning or diagnostics, make sure a crash cart is nearby. (A former boss died during an MRI because one was not available.)
- Ask your local hospital board if they have a Quality Committee that reports to the entire Board. Some 10% do not.
- Select providers based on outcomes using CMS databases and other sources of information.
- Secure a family member or friend to be your advocate when receiving care.
- Speak out if you suspect an error is about to occur or has occurred. A mother in the UK feared her child’s rash was sepsis but trusted the doctor who disagreed. Her child died of sepsis. “Molly’s Law” will allow any parent to demand a multi-physician clinical review of their child’s case.
If you have a “me too” healthcare error that you can share confidentially with me, please do so at email@example.com
NOTE: I sit on a subsidiary board of The Joint Commission. The opinions expressed here are mine and mine alone. I am writing as an economist.