Many experts say that medicine needs standardized rules similar to those in aviation, which bar takeoff until a pilot and co-pilot complete a prescribed checklist without interruption. Airlines have a vested interest in a culture of safety that Stahel says medicine lacks. In surgery “sometimes people say, ‘Well, this isn’t quite right, but someone else will address it.’ In aviation they don’t do that, because the plane will crash and they will all die,” he said.
“Health care has far too little accountability for results. . . . All the pressures are on the side of production; that’s how you get paid,” said Hopkins’s Pronovost, who adds that increased pressure to turn over operating rooms quickly has trumped patient safety, increasing the chance of error.
Kenneth W. Kizer, who coined the term “never event” nearly a decade ago when he headed the National Quality Forum, a leading patient safety organization, said he believes reducing the number of errors will require tougher reporting rules and increased transparency. Kizer, California’s former chief health officer, advocates mandatory reporting of wrong-site errors to a federal agency so cases can be investigated and the results publicly reported.
“How can you say these things should not be reported?” asked Kizer, director of the Institute for Population Health Improvement at the University of California at Davis. “These are the health-care equivalent” of plane crashes.
Shepard Hurwitz, director of the American Board of Orthopaedic Surgery, said he believes withholding payment for errors may prod hospitals fearful of offending their medical staffs to enforce safety rules and take action against recalcitrant doctors. “I think before it was thought to be the cost of doing business,” Hurwitz said. “I think the first time it happens, the person should be taken out of circulation until they understand what they did wrong. And if it happens again, they’re finished.”
One surgeon’s mea culpa
Hand surgeon David C. Ring was in his office at Massachusetts General Hospital dictating notes when the sickening realization hit him: The carpal tunnel release he had just completed was the wrong surgery.
“It was the worst feeling of my life: The ground literally falls beneath you,” Ring recalled in an interview. He returned to the operating room and informed the staff, then apologized to the 65-year-old patient, who spoke only Spanish and agreed to let him perform the correct surgery, a trigger finger release.
Several factors contributed to Ring’s mistake, which he wrote about last year in the New England Journal of Medicine; chief among them was the failure to perform a timeout because of various distractions.
The patient did not file a lawsuit, and Ring said the hospital paid her a modest amount in compensation. As a result of the case, safety monitors were assigned to the hospital’s operating rooms, and nurses were instructed not to hand the knife to the surgeon until the timeout is completed.
“I was an advocate before, but now I really believe in safety systems,” said Ring, who speaks to medical groups and says he still “tears up” when discussing the error. “I don’t want any patient or doctor to feel like I felt.”
This story was produced through a collaboration between The Post and Kaiser Health News. KHN is a news service of the Kaiser Family Foundation, a nonpartisan health-care policy research organization unaffiliated with Kaiser Permanente.
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