According to a report in the American Medical News
(American Medical Association) posted January 21, 2013, “never events” (surgical mistakes) occur 80 times a week, adding up to $1.3 billion in medical liability payouts over 20 years. They are “never events” because safety advocates say they never should happen. Although the Joint Commission, which accredits hospitals, has a “Universal Protocol
” (for Preventing Wrong Site, Wrong Procedure, and Wrong Person SurgeryTM
) intended to prevent these events, it has not solved the problem. The president of the Joint Commission talking about timeouts as one way of reducing errors said, “There are about 300 ways that timeouts can fail, from not having everyone stop what they’re doing and paying attention . . .
to having a bad safety culture where somebody knows something’s wrong but is too scared to speak up
” [emphasis mine].
This posting deals with “never events” in Britain. The reason this blog often draws inspiration from articles on the British National Health Service is there is ample evidence that the designers of the Affordable Care Act drew upon the British paradigm in designing the first step in the United States towards a single payer healthcare system. Thus, when the British press or BBC reveals serious shortcomings in the NHS we can see these examples as harbingers of what well may become prevalent in the American healthcare system or, in the case of the following example what probably already exists.
As a July 26, 2015
, online article on the BBC News site pointed out “bosses in all fields can make mistakes. And while junior staff may always feel uncomfortable pointing them out, in some areas failing to do so could cost lives. Aviation and medicine are two professions with a hierarchy that exists can make it particularly difficult for those lower down the pecking order to speak out.”
A terrible airplane crash occurred in Tenerife on March 27, 1977 where 583 were killed. This happened because of something the airlines call the authority gradient, meaning the captain, thinking they had been cleared for takeoff, overruled the copilot. Since that event airlines have promoted a culture where reporting errors is encouraged in order to prevent disastrous results. In the UK, doctors are being trained in safety measures based on research into aviation psychology.
In one example, the article describes an operation to repair a child’s hand. A lower ranking staff member noticed that the surgeon was going to start on the wrong hand. She tried several times to point this out but the senior surgeon just told her to shut up. Ten minutes into the operation the team realized it was operating on the wrong hand. So now surgical staff is taught techniques such as “trigger phrases” like “I am concerned, I am uncomfortable, this is unsafe,” or even more but bluntly, “we need to stop.” Even senior doctors reportedly can have a “light bulb moment” after taking such a course. The hope is never again to have as many errors as in 2012-2013 when there were nearly 300 events in which serious harm or death occurred that could have been completely prevented by a Junior speaking up and a Senior doctor listening to the warning.
Of course, if you are in a hospital for surgery you probably have no idea whether your surgical staff has had any of this kind of training. One possible clue would be to ask the chief surgeon whether the operating room personnel follow the World Health Organization’s (WHO) Operating Checklist
. This list breaks down surgical safety into three periods: before anesthesia begins; before there is an incision in the skin; and before the patient leaves the operating room. The WHO list also notes
the checklist is not intended to be comprehensive; rather, additions and modifications to fit locla practice are encourage.
You probably have been asked a few of these questions, like confirming your identity. American hospitals tend to ask your birthday, which interestingly is not on the list. You should also be asked to confirm what procedure is being done, where it is being done and that you have given consent. Here are the rest of things that according to the WHO checklist should happen at sign in and before the scalpel hits the skin:
o ANAESTHESIA SAFETY CHECK COMPLETED
o PULSE OXIMETER ON PATIENT AND FUNCTIONING
DOES PATIENT HAVE A KNOWN ALLERGY?
DIFFICULT AIRWAY/ASPIRATION RISK?
o YES, AND EQUIPMENT/ASSISTANCE AVAILABLE
RISK OF >500ML BLOOD LOSS(7ML/KG IN CHILDREN)?
o YES, AND ADEQUATE INTRAVENOUS ACCESS AND FLUIDS PLANNED
Before any incision there are seven items on the checklist including confirmation that all the team members have introduced themselves by name and role and that the surgeon, anesthesiologist and nurse have verbally confirmed the patient, site and procedure.
Before the patient leaves the operating room, the nurse should verbally confirm with the team:
o THE NAME OF THE PROCEDURE RECORDED
o THAT INSTRUMENT, SPONGE AND NEEDLE COUNTS ARE CORRECT (OR NOT
o HOW THE SPECIMEN IS LABELLED (INCLUDING PATIENT NAME)
o WHETHER THERE ARE ANY EQUIPMENT PROBLEMS TO BE ADDRESSED
o SURGEON, ANAESTHESIA PROFESSIONAL AND NURSE REVIEW THE KEY CONCERNS FOR RECOVERY AND MANAGEMENT OF THIS PATIENT
If you ask your chief surgeon about their Universal Protocol or the WHO Operating Checklist” and they draw a blank or do not tell you about their version, you might want to consider whether you are in the right place.