“Medical Error The Third Leading Cause of Death in the US”

“Medical Error The Third Leading Cause of Death in the US”

Makary and Daniel (Johns Hopkins) recently published a paper in the BMJ titled “Medical error—the third leading cause of death in the US”.   Their paper reiterates what many have had concerns about over the past decade or so: in spite of our best efforts, it is not clear that over the past decade we have made significant progress in eliminating adverse events in our Hospitals. If that is not enough, anyone who follows safety concerns/events on Twitter and other social media, will recognize that the public is made acutely aware of these facts on a daily basis (“Hospital probed after patient catches fire during surgery” May 5 2016- HorrorFansClub). Dr. Makary’s name may be familiar in that he and the Johns Hopkins group have been involved in projects over the past several years, evaluating teamwork and briefings in the O.R. (long list on Pubmed).

           This was a timely paper in that at our recent 40^th Annual meeting of the Association of VA Surgeons, Dr. LD Britt, past president of the American College of Surgeons and current member of the Joint Commission, expressed concerns that as a nation we have not made significant headway in the limitation of adverse events or their consequences and issued a challenge to the AVAS and VA to address this head on. On that note, this past Summer Doug Paul and I discussed a NCPS paper that reported the multitude of factors leading to adverse event that originate either prior to after the universal protocol (upstream and downstream). Following this conversation we initiated a collaborative assessing wrong level spine and pain intervention. The key conclusion of this initiative was that we can implement as many policies, rules, regulations and technology that we desire but without humans taking the initiative to understand the implications of human factors in the creation of mistakes we will likely not make further progress.

In their paper, Makary and Daniel proposed 3 strategies to reduce death from medical care:

1. Making errors more visible when they occur so their effects can be intercepted (end the shame and blame technique);
2. Having remedies at hand to rescue patients  (discuss upfront potential issues that could create a mistake, their consequences and how we will handle that);
3. Making errors less frequent by following principles that take human limitations into account (fig 2⇓) (make it easier for people by identifying the more likely positions in a process that we will make a critical error, create a pause, assure everything is ok and then proceed).

I have discussed this with educators and we don’t want to cripple people by making them overthink every single process but focus on the very critical points and assure we are communicating effectively should be a good first step.

It will be interesting to discuss this paper with Dr. Makary if he has the time.

KENNETH A. LIPSHY, MD, FACS

www.crisismanagementleadership.com

“Medical Error The Third Leading Cause of Death in the US”

“Medical Error The Third Leading Cause of Death in the US”

Makary and Daniel (Johns Hopkins) recently published a paper in the BMJ titled “Medical error—the third leading cause of death in the US”.   Their paper reiterates what many have had concerns about over the past decade or so: in spite of our best efforts, it is not clear that over the past decade we have made significant progress in eliminating adverse events in our Hospitals. If that is not enough, anyone who follows safety concerns/events on Twitter and other social media, will recognize that the public is made acutely aware of these facts on a daily basis (“Hospital probed after patient catches fire during surgery” May 5 2016- HorrorFansClub). Dr. Makary’s name may be familiar in that he and the Johns Hopkins group have been involved in projects over the past several years, evaluating teamwork and briefings in the O.R. (long list on Pubmed).

           This was a timely paper in that at our recent 40^th Annual meeting of the Association of VA Surgeons, Dr. LD Britt, past president of the American College of Surgeons and current member of the Joint Commission, expressed concerns that as a nation we have not made significant headway in the limitation of adverse events or their consequences and issued a challenge to the AVAS and VA to address this head on. On that note, this past Summer Doug Paul and I discussed a NCPS paper that reported the multitude of factors leading to adverse event that originate either prior to after the universal protocol (upstream and downstream). Following this conversation we initiated a collaborative assessing wrong level spine and pain intervention. The key conclusion of this initiative was that we can implement as many policies, rules, regulations and technology that we desire but without humans taking the initiative to understand the implications of human factors in the creation of mistakes we will likely not make further progress.

In their paper, Makary and Daniel proposed 3 strategies to reduce death from medical care:

1. Making errors more visible when they occur so their effects can be intercepted (end the shame and blame technique);
2. Having remedies at hand to rescue patients  (discuss upfront potential issues that could create a mistake, their consequences and how we will handle that);
3. Making errors less frequent by following principles that take human limitations into account (fig 2⇓) (make it easier for people by identifying the more likely positions in a process that we will make a critical error, create a pause, assure everything is ok and then proceed).

I have discussed this with educators and we don’t want to cripple people by making them overthink every single process but focus on the very critical points and assure we are communicating effectively should be a good first step.

It will be interesting to discuss this paper with Dr. Makary if he has the time.

KENNETH A. LIPSHY, MD, FACS

www.crisismanagementleadership.com

Post Mission Performance improvement Review- Lessons Learned from a $450,000 US F35 Lightening helmet.

Post Mission Performance improvement Review- Lessons Learned from a $450,000 US F35 Lightening helmet.
                  What does a $450,000 F35 Lightening helmet have to do with PI in surgery?
Last week I watched the USAF Heritage Flight team composed of an F22, F35 and a WWII plane and was awestruck by our modern fighters. But the flight was nothing compared to what I learned about the $450,000 custom fitted helmet each F35 pilot wears. I stopped to talk to a crew member when up walked Gen. Herbert J. "Hawk" Carlisle Commander, Air Combat Command, Langley Air Force Base, Virginia. He explained in detail the comparisons and unique differences between the F35 and F22.  More fascinating than the plane was the description of the custom made helmet which has dual projectors that provide data for the pilot on the face mask shield (See Photo of plane, helmet and the 4Star General). But what intrigued me most was the ability for the pilot to walk off the plane, head to the debriefing room, plug the helmet in and go thru the data for performance improvement. Yes-they debrief after every flight for performance improvement purposes.
                Earlier this month at the AVAS 40th annual meeting, Justin Dimick, MD, FACS (Chief of the Division of Minimally Invasive Surgery, and Director of the Center for Healthcare Outcomes & Policy at the University of Michigan) presented their success in video based coaching in Michigan in his talk INNOVATIVE STRATEGIES FOR IMPROVING SURGICAL PERFORMANCE.  I will go more into detail about his talk in our upcoming newsletter, but it is clear from his preliminary results that this process of reviewing films with peers will result in performance improvement.  When we work in a non-competitive collaborative environment, it is clear we can improve how we operate. As Malcolm Gladwell clearly notes in his book ‘BLINK’, what we perceive we did and what really occurred are not always the same. Reviewing a video of oneself can clearly erase the barriers we face during the process of change.  Let's face it, pilots have been debriefing for a hundred years so maybe we really have no excuse for not following suit.

KENNETH A. LIPSHY, MD, FACS

www.crisismanagementleadership.com

Post Mission Performance improvement Review- Lessons Learned from a $450,000 US F35 Lightening helmet.

Post Mission Performance improvement Review- Lessons Learned from a $450,000 US F35 Lightening helmet.
                  What does a $450,000 F35 Lightening helmet have to do with PI in surgery?
Last week I watched the USAF Heritage Flight team composed of an F22, F35 and a WWII plane and was awestruck by our modern fighters. But the flight was nothing compared to what I learned about the $450,000 custom fitted helmet each F35 pilot wears. I stopped to talk to a crew member when up walked Gen. Herbert J. "Hawk" Carlisle Commander, Air Combat Command, Langley Air Force Base, Virginia. He explained in detail the comparisons and unique differences between the F35 and F22.  More fascinating than the plane was the description of the custom made helmet which has dual projectors that provide data for the pilot on the face mask shield (See Photo of plane, helmet and the 4Star General). But what intrigued me most was the ability for the pilot to walk off the plane, head to the debriefing room, plug the helmet in and go thru the data for performance improvement. Yes-they debrief after every flight for performance improvement purposes.
                Earlier this month at the AVAS 40th annual meeting, Justin Dimick, MD, FACS (Chief of the Division of Minimally Invasive Surgery, and Director of the Center for Healthcare Outcomes & Policy at the University of Michigan) presented their success in video based coaching in Michigan in his talk INNOVATIVE STRATEGIES FOR IMPROVING SURGICAL PERFORMANCE.  I will go more into detail about his talk in our upcoming newsletter, but it is clear from his preliminary results that this process of reviewing films with peers will result in performance improvement.  When we work in a non-competitive collaborative environment, it is clear we can improve how we operate. As Malcolm Gladwell clearly notes in his book ‘BLINK’, what we perceive we did and what really occurred are not always the same. Reviewing a video of oneself can clearly erase the barriers we face during the process of change.  Let's face it, pilots have been debriefing for a hundred years so maybe we really have no excuse for not following suit.

KENNETH A. LIPSHY, MD, FACS

www.crisismanagementleadership.com

VULNERABILITY AND RESILIENCY- A LESSON ON HUMANITY FROM TIM LEEUWENBURG.

VULNERABILITY AND RESILIENCY- A LESSON ON HUMANITY FROM TIM LEEUWENBURG.

        This may be old to some, but I watched a heartfelt video from a presentation Tim Leeuwenburg gave at a few months back on dealing with our vulnerabilities “ALL ALONE ON KANGAROO ISLAND” Vimeo.com/130819016. Without giving the talk completely away he goes through his journey of anguish and shame during a misdiagnosis, leading to a patient who went septic, and subsequently became paralyzed, only to learn a nurse at the receiving facility told the wife she should sue him. After a two-year ordeal (alcohol, suicidal ideation…) he was able to reconcile with his patient and his wife. Later he describes his ability to look differently at life leading to his ability to maintain empathy and compassion at a different level. Sadly, he received the typical support we all do when we endure a tragic situation resulting from our own mistake.

       I began to recall the ACS papers a few years back on burnout in surgeons and the high association with medical errors, subsequent distraction, more errors, abuse and potentially suicide. About the same time the ASA published a paper in 2012 about how rare it is for an anesthesiologist to take the day off after having just witnessed a tragedy in the OR. I recently conversed with a CRNA who relived a story with me, whereby he watched an unfortunate mother die of hemorrhage after a delivery complication, and simply had to move onto the next case. My point is that, last year I chatted with a local Sherriff Deputy who was a State Trooper and asked him how they handle this in the police service. He relayed to me the story of how he was called at 2am on a 10 degree January day to a scene where an intoxicated driver speeding the wrong way on the interstate, slammed into a car with four college coeds. He said he had seen a lot by that point in his career, but nothing prepared him for the scene he walked into. A decade later he remembers vividly that when he arrived, the steam was pouring off the bodies which were severed in two by the seatbelts. I asked if he had to go back to work (like we do). I was surprised when he said that a Police counselor responded to the scene to assess if they were fit for duty. He was clearly not, so they found a replacement for him.  On that note, I asked Dan Linskey (ex Police Chief in Boston and incident commander during the marathon massacre) and he too said their police force relied heavily on on-the-scene therapist to assure that people were fit to go on or needed time to recover. So it seems that our first responder services do a better job of tending to their professionals than we do.

               So back to this video…Dr. Leeuwenburg explains how we are all vulnerable. We often are afflicted by shame or guilt in our profession. These unfortunately unclothe our vulnerability when we are exposed to medical error, administrative frustration (and our less than admirable responses), own expectations, and work-life imbalance. We quickly find a difference between our expectations and reality and are disappointed. As physicians, we idealize perfection and are less than satisfied by “good enough”.  His lessons in the end were to work towards resilience (and not alone but with others). Accept we are not alone in this battle and have empathy towards others who may be suffering (be kind). Be prepared to expose your own vulnerability to help yourself and others. In the end, he displays his transition in dealing with human suffering as he describes his care of a brave fire-fighter with lethal injuries, providing a humane approach and a lasting conversation with the fire-fighter’s wife.

 I hope this video is motivation to change how we deal with tragedy, mistakes and stress in medicine. I really would like to chat with Dr. Leeuwenburg at some point on this.

KENNETH A. LIPSHY, MD, FACS

www.crisismanagementleadership.com

VULNERABILITY AND RESILIENCY- A LESSON ON HUMANITY FROM TIM LEEUWENBURG.

VULNERABILITY AND RESILIENCY- A LESSON ON HUMANITY FROM TIM LEEUWENBURG.

        This may be old to some, but I watched a heartfelt video from a presentation Tim Leeuwenburg gave at a few months back on dealing with our vulnerabilities “ALL ALONE ON KANGAROO ISLAND” Vimeo.com/130819016. Without giving the talk completely away he goes through his journey of anguish and shame during a misdiagnosis, leading to a patient who went septic, and subsequently became paralyzed, only to learn a nurse at the receiving facility told the wife she should sue him. After a two-year ordeal (alcohol, suicidal ideation…) he was able to reconcile with his patient and his wife. Later he describes his ability to look differently at life leading to his ability to maintain empathy and compassion at a different level. Sadly, he received the typical support we all do when we endure a tragic situation resulting from our own mistake.

       I began to recall the ACS papers a few years back on burnout in surgeons and the high association with medical errors, subsequent distraction, more errors, abuse and potentially suicide. About the same time the ASA published a paper in 2012 about how rare it is for an anesthesiologist to take the day off after having just witnessed a tragedy in the OR. I recently conversed with a CRNA who relived a story with me, whereby he watched an unfortunate mother die of hemorrhage after a delivery complication, and simply had to move onto the next case. My point is that, last year I chatted with a local Sherriff Deputy who was a State Trooper and asked him how they handle this in the police service. He relayed to me the story of how he was called at 2am on a 10 degree January day to a scene where an intoxicated driver speeding the wrong way on the interstate, slammed into a car with four college coeds. He said he had seen a lot by that point in his career, but nothing prepared him for the scene he walked into. A decade later he remembers vividly that when he arrived, the steam was pouring off the bodies which were severed in two by the seatbelts. I asked if he had to go back to work (like we do). I was surprised when he said that a Police counselor responded to the scene to assess if they were fit for duty. He was clearly not, so they found a replacement for him.  On that note, I asked Dan Linskey (ex Police Chief in Boston and incident commander during the marathon massacre) and he too said their police force relied heavily on on-the-scene therapist to assure that people were fit to go on or needed time to recover. So it seems that our first responder services do a better job of tending to their professionals than we do.

               So back to this video…Dr. Leeuwenburg explains how we are all vulnerable. We often are afflicted by shame or guilt in our profession. These unfortunately unclothe our vulnerability when we are exposed to medical error, administrative frustration (and our less than admirable responses), own expectations, and work-life imbalance. We quickly find a difference between our expectations and reality and are disappointed. As physicians, we idealize perfection and are less than satisfied by “good enough”.  His lessons in the end were to work towards resilience (and not alone but with others). Accept we are not alone in this battle and have empathy towards others who may be suffering (be kind). Be prepared to expose your own vulnerability to help yourself and others. In the end, he displays his transition in dealing with human suffering as he describes his care of a brave fire-fighter with lethal injuries, providing a humane approach and a lasting conversation with the fire-fighter’s wife.

 I hope this video is motivation to change how we deal with tragedy, mistakes and stress in medicine. I really would like to chat with Dr. Leeuwenburg at some point on this.

KENNETH A. LIPSHY, MD, FACS

www.crisismanagementleadership.com

ERRORS OF OMMISSION OR COMMISSION- a call with Carla Pugh

      In our discussion about the book Crew Resource Management for the Fire Service, Senator Lubnau mentioned that under duress 60% of FIRE FIGHTER errors are those of COMMISSION -where we carry out a task incorrectly and the rest are errors of OMMISSION - where we neglected to carry out a task element.

    Dr. Carla Pugh was kind enough to discuss The University of Wisconsin groups study assessing how residents either succeeded or failed to recognize that an operative error occurred (typically errors of commission or omission) and then comprehend the steps necessary to adapt to the new uncertain situation- ie reverse/salvage the error.  (D’Angelo AL, Pugh CM et al. Error Management: Do residents identify operative errors as reversible.)

       This brings to light the two problems we face: 1. Do we rehearse the case in advance to identify the most likely critical points where a mistake is going to be made so we can pause and assure that happens. This was one area that Dr. Pat Croskerry advised is an opportunity in critical thinking we often avoid but need to address. It is also an area that  Dr’s Zenati and Tarola in West Roxbury are working on in which they are using the HUB system to  automatically introduce alerts during cardiac bypass and valve procedures whereby critical steps need to be focused on and avoid errors of omission. 2. Do we have the capability to understand when an error occurs what mechanics are needed to salvage / reverse the error?

I am hoping Dr. Pugh and I have more opportunities to discuss this.

Kenneth A. Lipshy, MD, FACS
www.crisismanagementleadership.com