Way back in 2004, when Dennis O’Leary, M.D., announced that the Joint Commission, which he at that time headed, was unveiling mandatory rules to prevent operations on the wrong patient or body part, he spoke out bluntly about a problem that is so obvious as to be egregious. “This is not quite ‘Dick and Jane,’ but it’s pretty close,” O’Leary, a former surgeon, was quoted as saying.
And even though the Medicare program has classified surgery on the wrong person or body part (for example, amputation of the wrong foot, a tragically not-uncommon occurrence) as a “never event” for which reimbursement should be withheld, seven years after the Joint Commission’s announcement of its universal protocol for this type of medical error, it continues to take place, at an alarming rate.
As a Kaiser Health News/ Washington Post article by Sandra G. Boodman, published on June 20, notes, Joint Commission officials are reporting that wrong-site surgery appears actually to be on the rise. That’s right: last year, 93 cases were reported to the Joint Commission, compared with 49 in 2004. What makes this even more shocking (if that’s possible) is that reporting such cases to the Joint Commission remains voluntary and confidential, in order to encourage clinicians and hospitals to report such medical errors and improve their patient safety—which means that that figure of 93 is likely artificially low.
Indeed, as the KHN/Post article notes, half of the states in the U.S. do not require such reporting, and it is voluntary reporting from the states that feeds the Joint Commission database. In fact, in two states that do track and intensively study such errors, 48 cases were reported in Minnesota last year, up from 44 in 2009, while Pennsylvania has averaged about 64 cases each year for the past few years.
The KHN /Post story goes on to catalog a few stomach-turning examples from the recent past, including a Portland, Oregon case in which an ophthalmologist recently operated on the wrong eye of a four-year-old boy, and a series of three wrong-site spinal surgeries in a two-month period at a respected academic medical center in Boston.
Anyone who has read Dr. Atul Gawande’s Checklist Manifesto will immediately recognize how much of a process problem this is in healthcare. It’s not about the competency of individual clinicians or staff members; it’s about process and flow. More often than anyone wants to admit or think about, patients are accidentally given test results for someone else; vertebrae to be operated on in spinal surgeries are incorrectly marked; or the wrong limb (strangely often a foot) is marked with a magic marker in the run-up to an amputation.
Tragically, the culture of secrecy, blame, and power dynamics that has historically been ingrained in hospital operations and culture continues forward in many organizations. And it is that culture that is partly to blame for the outrageous number of incidents a year in this area, as it turns out that oftentimes, someone does notice that something is amiss, but is afraid to say anything. Very often, this is a nurse who sees that a surgeon is about to make a terrible mistake, but who feels the icy hand of silence preventing a shout-out that could save the situation. Who can question a surgeon, after all? The fear of retribution remains chillingly real in so many institutions. And the power dynamics within hospitals, and the culture of secrecy and silence, continue to haunt the current patient care environment, to the detriment of patients and families.
Fortunately, some things are beginning to change, and there are now hospitals in which surgeons can be stopped from making the wrong moves. But it takes two things to fundamentally alter the ongoing recipe for disaster that is wrong-site surgery. One of these is an deliberate and lasting change in the culture of hospitals, wherein every person who has any involvement in any patient care delivery process feels empowered to speak up and can intervene to avert a disaster.
And the other is the intelligent leveraging of automation. Using the right forms of clinical decision support, protocols, and other tools, can absolutely change this equation, if the forms of automation and information involved can be made truly useful to clinicians at the point of care. As Dr. Gawande so eloquently demonstrated in his book, checklists work. But they have to be intelligently applied, and, as so many experts have said to me over the years, we have to make it more difficult to make a mistake or act unthinkingly, by putting every possibly useful tool at the disposal of clinicians at the point of care.
There are so many things in healthcare that need to be improved that the list can be overwhelming, as well all know. But can’t we get this “one” thing right? And of course, I put the word “one” in quotation marks, because of course, this is in fact about the overlapping of many dynamic processes in a sometimes-frenetic environment, one strongly predisposed from the outset to interruptions and distractions.
But honestly, how long will this go on? I remember that way back in about 1992, when a very infamous case of wrong-foot amputation took place in Florida that received tremendous mainstream media attention, leaders across healthcare were saying even then how this must not go on, etc., etc. And back then, the level of automation in hospitals was, of course, primitive compared to what it is now. Yet 20 years later, wrong-site surgery appears either to be on the rise, or perhaps there is better reporting of it. In any case, it has clearly not disappeared.
So, invoking the ancient Greeks and their Roman successors, we must first do no harm. And in order to do no harm, we’re going to have to intelligently leverage clinical IT, along with massive doses of sustained performance improvement, in order to fix this situation, so that 20 years from now, we’re not still expressing the same level of shock at the persistence of wrong-site surgeries that we are today.