Early in my career as a product manager working for a medical technology company, I witnessed a wrong site surgery. I was supporting a minimally invasive lumbar spine procedure, where the wrong level was treated. At the time I was unaware of exactly what was happening, and nobody in the OR spoke up. And then, when I thought we were going to be closing the case, there was a scramble of unexpected activity and chatter in the surgical field. I definitively remember the sinking feeling in my gut as the surgeon repositioned all the instruments to redo everything and perform the procedure at the correct level. I have no idea what, if anything, was reported, what the patient was told, or what was the ultimate clinical outcome.
I was reminded of this event listening over the weekend to a recent episode of Dr. Death, a popular and dramatic podcast reporting on patient harm and the medical system that fails them. This episode features an interview with Dr. Danielle Ofri, an internal medicine physician as well as author of multiple books and essays. Dr. Ofri is a foremost advocate for patient safety and a positive patient-physician relationship. Her recent book When We Do Harm: A Doctor Confronts Medical Error, discusses the cause of medical errors, the shortcomings of EMRs (electronic medical records), and missed diagnoses.
Anybody that has been in the arena of treating patients has witnessed errors. In contrast to the exceedingly bad individuals reported on in Dr. Death, most people are doing their best to do the right thing. Errors are committed by caring and well-intentioned clinicians. But many mistakes go unreported and that limits the opportunity for improvement. Making a mistake isn’t as bad as long as you or others can learn from them. Unfortunately nobody can learn if they’re not talked about.
Dr. Ofri shares a personal experience with her own near miss that happened early in her career. Patient harm was avoided, but the potential of it was so devastating that she couldn’t talk about it for 20 years. She goes on to discuss the culture of medicine, and how it’s very challenging to admit errors—there is fear of humiliation, shame, lawsuits. Physicians in training are taught about errors during Morbidity and Mortality Conference—traditional, recurring conferences held by medical services at academic medical centers—where senior doctors present the tragedies of mistakes and the negative outcomes for patients and providers. Such a terrible picture is presented of the errors and of those committing them that it is inherently believed that only perfection will be tolerated.
Dr. Ofri suggests that to further amplify the challenge, a strict hierarchy plays a strong part in the culture of medicine. Certainly anyone is capable of making a mistake, but when a physician or surgeon does something wrong, there’s pressure to not report errors by nurses and other staff involved in patient care, not to upset the apple cart. Despite many physicians, nurses and hospital leaders working to change this culture, it is challenging to overcome.
One way to reduce medical errors is to use an improved system or adjunctive technology. The StartBox System encourages a change in the culture by flattening the hierarchy: all members of the healthcare team can review patient and procedure information, and flag incorrect or confusing elements of the procedure plan. Flagging anything questionable contributes to near miss analysis which can help prevent catastrophic events. By implementing the StartBox System, hospitals and providers can prevent wrong site surgery and make patients safer than ever before.
A study was conducted at a single site over a twelve-month period. Similarly to the experience reported in a peer-reviewed publication, patient harm was prevented and errors were captured. Additionally, a downward trend in near misses was observed, with zero reported during the last five months of the period. This suggests that the StartBox System can help healthcare facilities and providers improve their patient safety and risk profiles over time.
Kim Kramer will lead StartBox in capitalizing on its goals of mitigating risk, reducing medical liability costs and increasing healthcare operational efficiencies.
Innovative Technology System to Prevent Wrong Site Surgery and Capture Near Misses: A Multi-Center Review of 487 Cases