No caring and responsible physician or surgeon knowingly wants to harm a patient…to be responsible for a medical or surgical error…yet now, more than twelve years after the Institute of Medicine’s report drawing national attention to errors, the incidence of errors and reported harm to patients continues1. Every physician and surgeon should ask themselves why, and they should feel obligated to avoid medical and surgical mistakes in their practices and hospitals.
To date, altruism and professionalism haven’t worked, pay-for-performance programs haven’t worked, and regulations haven’t worked2. Estimates of avoidable injuries and deaths remain unchanged or are increasing, and readmissions remain unchanged at 15% to 24%3. Hospitals only voluntarily report errors, and these reports yield an error rate of about 1%. However, using a global trigger tool, the Institute of Healthcare Improvement estimates that the rate of adverse events is ten times the voluntarily reported rate4. Except in hospitals that strictly enforce a preoperative time-out and require the surgeon to sign the correct surgical site, the incidence of wrong-site surgery is increasing5. Why do we keep doing the same things over and over again and expect a different result?
Lucian Leape believes that there has been some progress in the patient safety movement6. We now have safe practices for both process and system issues, but he asks what is missing today in attempts to improve patient safety. “Why can’t we stop wrong-site surgery?” “Why don’t hospitals have 100% compliance with hand washing?” He believes, as I do, that patient safety is a moral issue…When a physician is wrong, someone else is hurt. There is no accountability. Leape states, “We are not going to get safe care until we want to see it happen.” Nevertheless, 56% of physicians believe that quality of care will decrease under current health-care reform7. Why do they think this, if the patient comes first and harm is to be avoided?
Atul Gawande has reported that deaths from surgical errors have decreased from 1.5% to only 1.2% since 2002 (unpublished data)8. This represents about 50,000 deaths per year in the United States. He states that the major reasons for this change are improvements in technique, use of minimally invasive procedures, use of protocols, improved communication, and, most importantly in his opinion, the frequent mitigation of operating-room disasters in modern intensive care units with specialty-trained personnel. The best hospitals have the best rescue rates. Gawande has demonstrated the benefits to patient safety of the use of checklists in hospitals in the United States and other countries. The reported use of surgical checklists has reduced deaths due to errors from 1.5% to 0.8% and inpatient complications from 11% to 7.0%9.
In October 2012, the National Association for Healthcare Quality released a report entitled “Call to Action: Safeguarding the Integrity of Healthcare Quality and Safety Systems.”10 In the report, they called for four actions: (1) establish accountability for the integrity of quality and safety systems, (2) protect those who report quality and safety findings, (3) report quality and safety data accurately, and (4) respond to quality and safety concerns with robust improvement. Such calls should be implemented by orthopaedic surgeons, by our professional organizations such as the AAOS (American Academy of Orthopaedic Surgeons), AOA (American Orthopaedic Association), ABOS (American Board of Orthopaedic Surgery), RRC (Residency Review Committee), and specialty societies; by hospitals and ambulatory surgery centers; and by insurers as well as by legislative and regulatory bodies.
The emphasis in the patient safety movement has been increasingly directed at systems issues, with few reports emphasizing individual mistakes and responsibility. In his early (1908) error classification system, Codman included system issues, although he did not differentiate them from errors related to individuals11. However, Codman emphasized the following individual errors, which remain important for surgeons: lack of technical skill or knowledge, lack of surgical judgment, lack of diagnostic skill, and lack of care. In this issue of JBJS, Matsen et al. report that these same four individual errors listed by Codman continue to be largely responsible for malpractice claims against orthopaedic surgeons…104 years later. Wong et al. also reported that, according to an AAOS member survey, orthopaedic surgeons are involved in 60% of reported errors12.
Patient safety through reduction of surgical errors continues to be of major importance to patients and all health-care providers. It remains a major concern that progress has been slow and minimal. It is difficult to predict how the needed changes to the culture will occur. However, I believe that increased leadership by physicians and our professional organizations is needed, combined with a true partnership with our patients. We must support disclosure and reporting of all errors, development of national registries, root cause analyses of errors (such as wrong-site surgery), computerized skills tests to assess fatigue in surgeons before they perform an operation, remedial training (including coaching programs) for those surgeons with high rates of errors or complications as well as for disruptive physicians, assessment and remedial training of surgeons with hazardous attitudes, use of surgical checklists, identification and reduction of unnecessary surgery and overuse of specific procedures, acceptance of clinical guidelines and appropriate use criteria, and other efforts to improve patient safety.
The list is long. Barriers to our success in improving our patients’ safety are substantial and include the lack of medical liability reform and fear that disclosure of our mistakes will have consequences such as potential loss of patients or income as well as public embarrassment. To be successful, I believe that we have to partner with our professional organizations, our patients, The Joint Commission, the American College of Surgeons (and other physician organizations), the ABOS (and other boards), the Accreditation Committee for Graduate Medical Education, the Centers for Medicare & Medicaid Services, insurers, and state and federal legislators. It is a huge task. Change will not be quick, but will be slow and difficult. However, change is essential.