16 January 2009

Surgery By The Book Can Save Lives

Following relatively simple checklists of precautions in connection with surgeries can dramatically reduce major medical mistakes.

Incidence rates of serious complications and deaths during and after major operations can be lowered by as much as one-third if doctors follow a simple surgical checklist, a new study has found. . . .

The research showed that rates of major complications fell from 11 per cent to 7 per cent after the checklist was introduced. Post-surgical complications include heart attack, stroke, pneumonia and blood clots.

The study also found that deaths following major surgery fell by a staggering 40 per cent after implementation of the checklist. . . .

The checklist was developed by an expert panel at the World Health Organization as part of its Safe Surgery Saves Lives initiative. It is a single page that takes only a few moments to complete, and covers three important junctures during operative care: before anesthesia is administered, before the incision is made and before the patient is removed from the operating room.

It asks a range of questions, such as:

* Does the patient have a known allergy?

* What are the critical or unexpected steps, operative duration, anticipated blood loss?

* Has sterility been confirmed?

* Are there equipment issues or any concerns?

According to Dr. Bryce Taylor, study co-author for Toronto General Hospital, it is not standard operating procedure for the entire surgical team to go through the steps of the surgery together and discuss any possible complications. . . .

Studies have shown that major complications occur in between three and 16 per cent of surgeries in industrialized countries. Death rates following surgery range from 0.4 to 0.8 per cent.

Complications and deaths can be attributed to a number of factors, such as inconsistent approaches to surgery. For example, while research has shown that administering antibiotics within one hour prior to incision can reduce the risk of a wound infection, not all hospitals follow this recommendation.

About the study:

The study, led by researchers from the Harvard School of Public Health, included hospitals from eight cities around the world including Toronto General Hospital.

The findings are published in the New England Journal of Medicine.

For this study, researchers collected data from more than 7,600 patients from October 2007 to September 2008. The study included one hospital each from Seattle, Toronto, London, Auckland, Amman, New Delhi, Manila and Ifakara, Tanzania.

Almost every significant study on medical mistakes has shown that a systems oriented, by the book orientation is the most effective way to improve outcomes. For example, most of the great improvements seen in trauma centers over other medical settings comes from a better set of systems and checklists.

Medical malpractice lawsuits, in contrast, focus heavily on individual mistakes of judgment by physicians, established through expert testimony. Many states, Colorado among them, provide as a matter of law that group medical practices, as opposed to individual physicians, cannot be held liable for medical malpractice, despite the fact that firm level procedures are central to bad outcome levels. The opposite rule, disallowing liability for individual doctors, while making it available without proof of individualized mistakes of judgments for medical practices and hospitals, would probably produce better incentives.

There is no meaningful mandatory regulation of how medical practice is conducted comparable to OSHA, which sets forth specific best practices that must be followed and can be sanctioned for non-compliance even in the absence of a bad outcome. Professional regulatory bodies address only gross incompetence or failure to observe ethical standards.

Physicians themselves often place great importance in individual expertise and tend to downplay or scorn having institutions impose limits on how they practice medicine, even if those limits are evidence based. Lawyers, for what it is worth, are even worse.

Tort liability for airline crashes, in contrast, approaches strict liability, and the National Transportation Safety Board's approach to airline safety, in contrast to most other governmental responses to accidents, treats almost every single serious incident as a systemtic problem.

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