Surgical Error

The Effect Of Creating And Using A Safety Checklist In Conjunction With The Performance Of Non-Cardiac Surgery

by Jerry Meyers on March 5, 2009

In January of 2009 the New England Journal of Medicine published the results of a study conducted by the Harvard School of Public Health at the Massachusetts General Hospital in Boston reporting the effect of creating and using a safety checklist in conjunction with the performance of non-cardiac surgery. Eight hospitals in eight cities as diverse as New Deli, India and Seattle, Washington participated in this study.

All hospitals who participated in this study employed a surgical safety checklist. Remarkably, none of the items involved new technology or surgical techniques.

The checklist items were as follows:

  1. Requiring each surgical patient to verify his or her own identity, surgical site and procedure.
  2. Marking the surgical site.
  3. Using pulse oximetry.
  4. Requiring that surgical team members pause to introduce themselves by name and role and then reviewing anticipated critical events.
  5. Confirming that prophylactic antibiotics were administered greater than sixty minutes before incision.
  6. Confirming needle and sponge counts and at completion of the surgery revealing key concerns for the patient’s recovery and care.

The implementation of the checklist items with respect to the non-cardiac surgical patients greater than 16 years of age resulted in a reduction in complications associated with the surgery from 10.3% to 7.1% and at high income study sites such as Seattle, Toronto, London, etc. the death rate diminished from .9% to .6%.

When one considers that 234 million operations are performed globally each year, a universal adoption of the checklist could result in saving as many as 702,000 persons annually worldwide.

Even more important, perhaps is the near 40% reduction in postoperative complications after introduction of the checklist. The checklist represents a potential for preventing postoperative complications worldwide annually by 9,360,000.

It is perhaps not so surprising that safe surgery requires an attention to very simple details which assure that all members of the team know what they are about.

Regrettably, there is no agency or law which compels our hospitals and healthcare providers to implement a surgical checklist. Indeed, the only tool available to families of patients harmed by medical negligence generally is the medical malpractice lawyer.

In Pennsylvania and many other states lawyers have fought to maintain the right of victims of medical negligence to seek justice in our courts. No doctor or other healthcare provider, hospital or otherwise is above the law.

The civil justice system provides an important incentive to healthcare professionals. There is no other effective mechanism for holding them accountable and assuring that those victims of medical negligence obtain the compensation they deserve to help them meet the great economic and other challenges which they face.

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Failure to Understand Allergy Leads to Woman's Death

by Jerry Meyers on May 27, 2008

Communication is essential between health care providers but sometimes communication fails because of the arrogance or carelessness of the persons involved in the needed medical communication.

Several years ago, a female client about to enjoy an important anniversary was admitted to a University affiliated hospital for the purpose of having a colostomy wound debrided (cleaned up).

This was to be a one-day inpatient hospital procedure and was associated with little to no risk. As a part of the procedure, however, a prophylactic antibiotic was to be administered.

Unfortunately in this particular case, when the antibiotic (Cefotin) was administered the patient suffered a sudden cardiac arrest. This cardiac arrest resulted from a rare but well-known allergic reaction to this antibiotic. The patient was successfully resuscitated.  No harm done.  A substitute antibiotic was employed uneventfully.  Because the patient suffered a cardiac arrest before her surgery could be performed,  the procedure was rescheduled to occur approximately thirty days later with the same surgeon who had earlier been involved.  The anesthesiologist, who had saved this patient’s life earlier,  recorded in the order sheet, in the progress notes and even in a typed signed note provided to the patient, notice of what had happened to her, “You are allergic to the drug Cefotan. Don’t allow this drug to be administered to you. You may die.” Who could have done more to protect the patient from a similar future occurrence?

The patient showed her surgeon the note her anesthesiologist had provided and,  rather than openly disagreeing with the note, he simply said he was aware of that.

Thirty days after the patient’s original cardiac arrest she was readmitted for a repeat of the same procedure that was originally planned. The patient had ugly premonitions about what might happen which she shared with the admitting nurse. The admitting nurse was sufficiently concerned that she assured the patient that an anesthesiologist would attend the patient before the patient went to the operating room to ease the patient’s mind. The anesthesiologist who came to the patient’s side assured the patient that everyone knew she was allergic to Cefotan.   She said reasuringly,”You will not receive Cefotan.”   Were she to receive Cefotan she might die.   The wristband the patient was wearing revealed the presence of this allergy as did numerous references in the hospital records that no one could possibly miss.   The anesthesiologist promised the patient, “You will not receive this drug.”

Notwithstanding all these assurances the patient went to the operating room for her one-day procedure and as the same anesthesiologist entered the room who had just offered such reassuring promises, this anesthesiologist observed the patient was about to receive a prophylactic antibiotic intravenously. The anesthesiologist promptly inquired as to the type of antibiotic and was told, “Well its  Cefotan.” The anesthesiologist replied, “But she is allergic to that.”

Amazingly, the surgeon present, who was the same surgeon present at the time of the original cardiac arrest, insisted that the patient get the prophylactic antibiotic and the anesthesiologist present and the nurse anesthetist present lacked the courage to refuse.  Instead the anesthesiologist said to the nurse anesthetist, Well, make sure you don’t give to much.”  The drug was administered.  The patient died.

These facts are taken from a real case. Agreements and legal restrictions prevent the identification of names and places or even institutions.

The case was concluded in such a way that all involved were aware of their involvement and what they did, how it contributed to the patient’s death and what should have been done otherwise.   It is not always possible to prevent malpractice before it occurs but it is certainly essential to see to it when it has occurred with unfortunate results that those involved are made aware of what they have done and with what consequence.   It is the least we can do to assure that it is less likely the catastrophe be repeated.

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