How to Avoid Malpractice

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Rahul Shah, MD, MBA, vice president and chief quality and safety officer at Children’s National Health System in Washington, D.C., opened a session on otology malpractice with a definition of quality. He described quality as the sum of outcomes, safety, and service and explained that patients want safety above all, followed by outcomes and value. Since the field of otolaryngology involves many highly complex tasks, the risk for harm is innately high, and therefore otolaryngologists must spend time thinking about safety.

To eliminate serious harm in any medical procedure, the community must first conceptualize the different aspects of patient safety. A growing body of literature has defined medical error, adverse events, and near misses. A medical error is the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. An adverse event is an injury, either physical or psychological, that is caused by or results from medical management, as opposed to the underlying disease. A near miss is an unplanned event that did not result in injury, illness, or damage, but had the potential to do so.

Dr. Shah then asked the question, “How do we build the constructs to not have errors in our practices?” Such a question prompts a drive to transform environments that have a rich potential for error into high reliability organizations that have a preoccupation with failure such that they regard small, inconsequential errors as a symptom that something is wrong. He suggested that the first step is to develop the practice of mindfulness (see sidebar), in which all members of the team are sensitive to operations and pay attention to events transpiring on the front lines.

In 2004, 60% of errors in the field of otolaryngology occurred during surgical management, with errors occurring most commonly during endoscopic sinus surgery (ESS) (see sidebar). The errors that provoke the most outrage, however, and receive the most publicity, are those that occur when surgeons perform surgeries on the wrong site or the wrong patient. “I hear about a couple of these every year,” added Dr. Shah.

Brian Nussenbaum, MD, execitive director of the American Board of Otolaryngology, explained that these wrong site/wrong patient errors are classified by the National Quality Forum as “never events.” Such errors in medical care are identifiable, preventable, and have serious consequences for patients. A closer examination of wrong-site surgeries reveals that they have several root causes. These could include hectic schedules, new teams, distractions, and a culture of hierarchy and fear.

Quality Improvement Initiatives

Dr. Nussenbaum described steps that hospitals can put in place to create a culture that reduces process errors. The first step is to identify all potential errors from scheduling and eliminate variation in the process of marking the correct surgical site. “These things aren’t always intuitive, even though you would think that they should be,” he said.