How to Stop "Never Events" in Health Care

In her December 20th blogpost on WonkBlog, Sarah Kliff reports on a study from the Journal Surgery which documents that surgeons have left 4,857 objects in patients over the last two decades. The study by researchers at Johns Hopkins University also documents that doctors operate on the wrong body site at least 20 times a week, and that they also perform the wrong procedure on a patient about 20 times a week. After analyzing data from malpractice cases, the researchers estimate that 80,000 of these “never events” actually happened in the past two decades. The study is based on data from malpractice claims. Thus, it may underestimate the kind of problems catalogued since not every “never event” becomes a legal event.

Never events in the United States. Chart via Sarah Kliff and Wonkblog.

Never events in the United States. Chart via Sarah Kliff and Wonkblog.

These “never” events could be dramatically reduced if surgeons used checklists – the kind that we have written about in our new book Beyond the Checklist: What Else Health Care Could Learn from Aviation Safety and Teamwork. They could also be reduced if hospitals cracked down on the minority of surgeons responsible for such problems. Doctors who leave instruments and other things inside the patient, or who operate on the wrong patient or body site have already had malpractice claims brought against them or are younger–and thus less experienced–surgeons.

This sorry record highlights the fact that healthcare facilities do not offer the kind of high reliability that saves lives and limits harm. They are not what Karl Weick and Kathleen Sutcliffe refer to in their excellent book, Managing the Unexpected: Resilient Performance in the Age of Uncertainty, as high reliability organizations (HROs).

The study by Johns Hopkins researchers explains that using mechanisms like timeouts (calling a time out to make sure that they are operating on the right person, at the right time, and on the right site) as well checklists in the OR helps to reduce medical errors and injuries. Errors and injuries are also reduced when surgeons take the time to brief and debrief OR staff and to flatten hierarchies among OR team members. It’s much better for patient safety, if your surgeon is on a first name basis with the OR staff – as in “call me Tom or Joanne, instead of Dr. Smith and Dr. Patel.” Why? Because safety advocates have found that it’s a whole lot easier to tell Tom or Joanne that they are about to make a mistake than to tell Dr.Smith or Dr. Patel. Which is why, airplane crews all use their first name and why the captain of the ship is required to brief the crew, use checklists, and debrief after any near misses or problem. This has made flying a whole lot safer than it used to be when toxic hierarchies were the norm and captains were kings who never listened to – or solicited – input from their crews, whether in the cabin or flight deck.

The kind of transformation that took place in aviation should, as Johns Hopkins researchers explain, serve as a guide for hospitals – particularly for surgeons. But today, hospitals have an amazing tolerance for physicians who continue to practice unsafely. Surgeons are often regarded as the “geese who lay the golden eggs.” Challenge them and they will go somewhere else to roost. I have seen hospital administrators sit passively by as staff tell them about physicians who refuse to use checklists and time outs, follow safety protocols, like washing their hands, or using masks to maintain sterile conditions. I have watched as nurses tell their managers or high-level administrators that they are afraid to call a particular surgeon in the middle of the night if they are unclear about a patient’s orders. (This is a potential catastrophe, since clarification of an order may make the difference between life and death for the patient). And yet no one does anything about that doctor, whose behavior, by the way, hospital higher ups may have known about for years.

I have heard surgeons tell other physician safety advocates that they couldn’t possibly flatten the hierarchy in the OR because their patients want them to be referred to as “Dr. this or that.” This in spite of the fact that most patients are unconscious in the OR or too snowed on anti-anxiety meds to care about what their doctor is called. (When I hear physicians explain that patients insist upon the maintenance of such toxic hierarchies I always wonder how these physicians know what their patients preferences really are. Have they actually explained that a flatter hierarchy is safer to their patients? After hearing such an explanation have patients actually argued that they prefer status-enhancing formality rather than practices that enhance their safety?)

In aviation, reports like those done by Johns Hopkins researchers produced concrete results – and fast. In healthcare there is certainly a path to safety – a way. What’s missing seems to be the will to challenge the few physicians who harm so many patients and who also give their colleagues a very bad name.

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