Introduction 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Atul Gawande has reported that deaths from surgical errors have decreased from 1.5% to only 1.2% since 2002 (unpublished data)8.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.