Since the publication of the Institute of Medicine’s report, To Err is Human,1 accumulating data have shown that patient safety systems are slowly improving. There is greater recognition of patient safety in the medical literature and more monetary awards for research regarding medical errors.2 Most quality improvement experts call for an acceleration of progress in order to meet the goals set out by institutions and organizations across medical specialties.3-8
In otolaryngology, Roberson et al. expressed to their colleagues that there is a well-defined body of knowledge that substantiates there is a minimum human error rate that can never be eliminated, and therefore, gaining a better understanding of systems-science principles can help clinicians provide better and safer care.9
How does otolaryngology differ from medical practice, general surgery, or other surgical subspecialties when it comes to medical errors? This question was posed at the heart of research conducted in the past five years by a team including Rahul K. Shah, MD; David W. Roberson, MD; and Gerald B. Healy, MD, at Boston Children’s Hospital.10,11 Dr. Shah, now with the Division of Otolaryngology at Children’s National Medical Center in Washington, DC, said that Dovey and Elder’s landmark work developing a taxonomy for medical errors in family practice12,13 was the inspiration for their research team when they subjected their specialty to the medical-error microscope.
Though the content from specialty to specialty will differ, said Nancy Elder, MD, MPH, Associate Professor of Family Medicine at the University of Cincinnati Medical Center, the systems that may be vulnerable to mistakes, adverse events, and near misses are largely the same. That was a good starting place, said Dr. Elder of their studies that examined medical errors and proposed a number of ways to classify them. Hospitals have been studied for much longer with regard to patient safety and quality of medical care than has the outpatient setting. What we know about the outpatient setting lags 20 years behind the hospital setting, but in the last 5 years there has been a lot of additional research in the ambulatory setting.
Key Concerns for Otolaryngologists
Small changes have the ability to result in outcomes that are far beyond what is predicted by incremental measures, wrote Shah et al. in their study outlining a classification of errors in otolaryngology.11 Dr. Shah, now Assistant Professor of Otolaryngology at George Washington University, and his team focused on medical errors specifically from the otolaryngologist’s view. We approach our research on a micro scale to recognize the problems that are occurring. Then, he said, they think about small changes that can have a big effect on the macro results.
The investigators distributed a retrospective, anonymous survey to 2,500 members of the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS), inquiring about errors that had been made in the previous six months (see sidebar). The overall response rate was 466 from 2,500 (18.6%) mailed surveys; 256 (55%) of respondents reported no error and 210 reported errors. There were 78 cases of major morbidity and nine deaths. Extrapolating the data, the researchers estimated that more than 2,600 episodes of major morbidity and more than 165 deaths related to error may occur annually in the care of otolaryngology patients.10
The team ultimately recommended that small changes could be taken in medical-surgical practices-changes that would be relatively inexpensive but could have a big effect on outcomes. How big an effect? That’s hard to say, said Dr. Shah. Systems research points to this all the time. You have no way to realize the significance of making a small change until you actually make it.9
A clear example of this is one Dr. Shah and his colleagues frequently mention in their lectures and presentations. As reported in 2004 in Laryngoscope,10 when they looked at error classification, we found the type of medication errors that everyone always talks about, he said.
One of the more common errors was with the use of concentrated epinephrine on the operative field. The well-publicized case that occurred in Florida and was reported at the first national conference on medical errors in 1996, in which a surgical team inadvertently injected a young boy with concentrated epinephrine at a dilution of 1:1000, two orders of magnitude higher than was appropriate, is well familiar to otolaryngologists. The child died on the operating table.
That really caught the media’s attention, said Dr. Shah, but when otolaryngologists heard about the case, they considered it an anomaly, something that cannot happen in my practice.14 Yet when we did our study, we saw that five out of eight errors in the category of wrong drug/dilution on the surgical field involved concentrated epinephrine.
The upshot of this was that the investigative team approached the Boston Children’s Hospital administration and recommended that vials of concentrated epinephrine not be allowed in the operating room. And they said okay, Dr. Shah said. That’s a simple solution that has huge ramifications. We had never had an incident in our hospital with concentrated epinephrine in the operating room, but we took a proactive, prophylactic measure to ensure that it would not happen in the future.
Stark Differences
The Boston team’s research showed two major findings. The first was that although there were similarities between primary care and otolaryngology regarding the errors that occur, there were also stark differences, which in effect reflect the overall differences between medical and surgical practice.
About 20 percent of the errors that we reported were surgical errors, said Dr. Shah. Those were technical errors, he said, adding that a taxonomy that would work for a medical specialty such as family practice would not be able to catch those types of errors. We had a lower rate of medication errors, and that doesn’t mean we’re [more proficient in that area], it just means we use [and prescribe] less medication, he said. As an otolaryngologist, I feel comfortable saying that 90 percent of what we prescribe is about the same 15 medications or fewer, whereas family practitioners could prescribe 50 different medications a day, so they have a higher chance of having more errors with that. Data that appeared more frequently in the survey responses reflected errors in diagnosis, delayed treatment, surgery, communication, and administration.
But in addition, comparing their findings with those of Gawande et al.,15,16 they found that there were differences between general surgery and the surgical subspecialties. Whereas much of general surgery is related to issues of greater acuity, such as for trauma or major cardiac or abdominal surgery, in otolaryngology, perhaps 80 percent of our surgeries are elective, said Dr. Shah. And we’re a high-volume specialty. So the types of errors we have are going to be different than a specialty that does only two surgeries a day. Some otolaryngologists perform 10 surgeries on a routine operative day.
When they continued developing their research plans, said Dr. Shah, one of our conclusions was that specialists should stick with what they know. It does not make sense for us to start researching general surgeons, just as it doesn’t make sense for cardiologists to research otolaryngologists. If we’re going to get accurate numbers, it’s really pertinent that each subspecialty studies itself.
Preventing Errors
Otolaryngologists can prevent medical errors in their institutions and practices with some very simple practices. Keep your eyes open, advised Dr. Shah. Begin to carefully observe what’s going on around you and focus your attention on details. He believed his physician colleagues would be frightened by the number of errors that occur on a day-to-day basis, but they might be more impressed by how simple they are to fix.15,16
As a fellow in pediatric otolaryngology, Dr. Shah was ignorant to these commonly occurring errors, he said, but once I started researching medical errors, I would take an extra three to five minutes on my morning rounds and flip through some of the charts with the residents. They began to see that a note was sometimes lost or where they thought they had documented something, in fact they had not. Sometimes verbal orders weren’t signed or there were illegible signatures.
These were simple things that could easily be fixed, he said. And I was at fault as well. My signature is horrendous. And then I took a step back, and asked myself: What if there is an emergency and the nurse needs to call the attending surgeon and she can’t read my signature? Although he signs his last name the same way, he now prints SHAH and adds his pager number.
Another simple remedy is the time out procedure, now a mandate of the Joint Commission for the Accreditation of Healthcare Organizations. Another means of helping to prevent errors is to know the names of all your teammates-everyone in the surgical suite. If there’s an emergency, when you know people’s names you can communicate better, said Dr. Shah. Dr. Roberson, Dr. Shah’s research mentor, routinely writes down the names of all team members in the operating room at the beginning of the day. This includes the circulators, the anesthesiologists and even the employees that turn over and clean the room between cases.
Standardization can also be a boon to preventing errors, and yet does not have to take away from a clinician’s autonomy.9 Indeed, we would argue, the opposite is true, said Dr. Shah. It frees you up to practice the art of medicine. Standardizing forms or protocols allows the practitioner to focus on making the diagnosis and developing a relationship with the patient. He admits that he had to sell himself on this concept. Five years ago I thought that standardized tonsillectomy and adenoidectomy postoperative forms were ridiculous. … But now I ask, why am I spending the extra five minutes to write individual orders for each patient when a standard form that results in fewer errors takes me a minute to fill out? Then I can spend the extra four minutes talking to the patient or teaching the residents. It’s a mind shift, he said, that can help any otolaryngologist improve quality and safety.
My residents are getting trained with a different culture; and not just mine, this is a nationwide experience with patient safety and quality being inculcated into residency training. So hopefully 15 to 20 years down the road, the same surgeons will be training their residents with the culture of safety.
Preventing Errors: Easy Fixes Make a Difference
- Notice the details of what you and your colleagues and staff members are doing.
- Use and advocate for surgical time-outs.
- Follow good medication practices: medication reconciliation, read backs on verbal orders, limit abbreviations, keep look-alike and sound-alike medications in separate locations; make careful choices regarding drug labeling, packaging, and storage.
- Practice leadership from the top down.
- Look for ways to make small changes that can have large ramifications.
- Don’t resist standardization; it can support your autonomy.
Where Are Errors Made in Otolaryngology?
Errors in otolaryngology were classified as related to:
- History and physical = 1.4%
- Differential or final diagnosis = 1.4%
- Testing = 10.4%
- Surgical planning = 9.9%
- Wrong-site surgery = 6.1%
- Anesthesia = 3.3%
- Wrong drug/dilution on the surgical field = 3.8%
- Technical = 19.3%
- Retained foreign body = 0.9%
- Equipment = 9.4%
- Postoperative care = 8.5%
- Medical management = 13.7%
- Nursing/ancillary = 0.5%
- Administrative = 6.6%
- Communication = 3.8%
- Miscellaneous = 0.9%
Source: Shah RK et al. Laryngoscope 2004;114:1322-35.
References
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