Pediatric Surgery NaT

Medical Errors

Kurt F Heiss, MD, Kuojen Tsao
Medical Errors is a topic covered in the Pediatric Surgery NaT.

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All surgeons come to work each day intent on providing good care to their patients. Because surgical procedures have the potential for both healing and harm, the surgeon is clearly the custodian of their patient’s safety. The American College of Surgeons (ACS) drafted a Code of Professional Conduct that states "Professionalism serves as the basis of the social contract between medicine and the society that it serves." The foundation of this social contract is the sacred relationship between patient and surgeon. Most surgeons do everything possible to provide safe care and ensure an optimal outcome. Surgeons are then understandably confused and threatened when told that their delivery of care may include preventable medical errors (PME).

In the last 20 years, improved public health tools, measurable data and a number of high visibility examples have changed the landscape of health care [1]. Patient safety has become a common theme in the lay press. Hospitals now focus great amounts of resources and effort to measure and provide demonstrably safer care [2]. The shared social contract of surgical professionalism coupled with increased scrutiny by hospital leadership and our surgical culture, it is important that pediatric surgeons recognize and understand the problem of adverse events and PME. As informed partners in the process we can provide leadership and contributions to improving patient care and safety.

Why is understanding medical errors the first step in preventing future adverse events?

A young Asian male is seen in a busy clinic with his Mandarin speaking parents. While examining the frightened child, a right inguinal hernia is identified and documented in the history and physical. A telephone translator communicates with the parents. The documentation is completed at the end of the day by the overworked surgeon. The office staff submits the paperwork to the operating room scheduler booking a left inguinal hernia repair for the child.

On the day of surgery the frightened and uncooperative child arrives, receives midazolam and sleeps through a verification exam that cannot reveal a hernia. The history and physical from the clinic is not reviewed. A band is placed on the child’s wrist rather than a marker being used to document the side of the hernia to avoid tattooing the skin. The father, who speaks some English, is not present. Using a phone translator the mother agrees to surgery. The patient is taken to the operating room and undergoes a negative left groin exploration. In spite of numerous checks (e.g. nurse verifications, surgeon verifications, anesthesia verification) a wrong site surgery occurs.

Why does an event like this occur when so much training and altruism is the cultural norm in surgery? The care we provide has become quite complex. In Halstead’s day surgical care was provided by a surgeon and a nurse. In contemporary health care, 20 people can touch a patient during a simple episode of care. With so many moving parts, the opportunity to drop the baton during a transfer of care is significant. Most surgeons are trained to work well as an individual. Contemporary care requires a team to deliver excellent care. In health care, few resources were dedicated to this team effect allowing errors to occur in complex medical systems [3][4]. Most surgical systems are now devoting increasing attention to simulation and the function of teams in trauma care. This has yet to spill over to the operating room. Unlike health care, other high reliability organizations spend hundreds of hours developing reliable team communication in order to provide reliable outcomes. Reason demonstrated that despite layers of safety policies, an adverse event can still reach the patient. This has become known as the swiss cheese effect [5]. As the efforts to measure and increase safety in patient care have provided modestly improved results, the importance of changing our culture has become more evident [6]. We have to change our attention from a process to something we feel.

What is the prevalence of medical errors in pediatric surgery?

In 1999, To Err is Human, was published by the Institute of Medicine [1]. This ground breaking report identified PMEs as a leading cause of patient harm and death. Prior to this report, systems had not been developed to measure the adverse events related to PMEs. The medical community recognized that unintentional and preventable errors were harming patients at an alarming rate. It was also recognized that PMEs increases the cost, length of stay and resource utilization in the health care system. Even before the IOM report, in 1994 Leape described the national burden of medical error [7]. He asked the question “if two jets crashed daily, the public wouldn’t stand for it . . . Why do we tolerate this level of error in healthcare?” The data supporting this alarming conclusion was a New York State Medicare based study which described an adverse event rate of four percent of all admissions. The mortality rate from this study suggested a national mortality rate of 100,000 lives/year in the United States from medical error [8][9]. Although critics attacked its methodology and conclusions, the conclusions were supported by similar studies published in Australia and the United Kingdom that suggested even higher adverse event and mortality rates [2][10][11]. Another study by Gawande suggested a similar but lower rate [12]. This data based acknowledgement of the problem opened the gates for others to talk about patient safety and improving quality.

Until recently, most pediatric hospitals had not measured patient injury or attempted to understand and reduce the rate. The Solutions for Patient Safety group began to measure and report and compare the rate of injury between hospitals [13]. The acknowledgement and addressing of the problem of injury has become the foundation and first steps for other pediatric institutions to follow suit. The injury rate and adverse event incidence has become a metric that surgeons are evaluated by.

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Last updated: August 28, 2017