Rahul Shah, MD, MBA, vice president and chief quality and safety officer at Children’s National Health System in Washington, D.C., opened a session on otology malpractice with a definition of quality. He described quality as the sum of outcomes, safety, and service and explained that patients want safety above all, followed by outcomes and value. Since the field of otolaryngology involves many highly complex tasks, the risk for harm is innately high, and therefore otolaryngologists must spend time thinking about safety.
To eliminate serious harm in any medical procedure, the community must first conceptualize the different aspects of patient safety. A growing body of literature has defined medical error, adverse events, and near misses. A medical error is the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. An adverse event is an injury, either physical or psychological, that is caused by or results from medical management, as opposed to the underlying disease. A near miss is an unplanned event that did not result in injury, illness, or damage, but had the potential to do so.
Dr. Shah then asked the question, “How do we build the constructs to not have errors in our practices?” Such a question prompts a drive to transform environments that have a rich potential for error into high reliability organizations that have a preoccupation with failure such that they regard small, inconsequential errors as a symptom that something is wrong. He suggested that the first step is to develop the practice of mindfulness (see sidebar), in which all members of the team are sensitive to operations and pay attention to events transpiring on the front lines.
In 2004, 60% of errors in the field of otolaryngology occurred during surgical management, with errors occurring most commonly during endoscopic sinus surgery (ESS) (see sidebar). The errors that provoke the most outrage, however, and receive the most publicity, are those that occur when surgeons perform surgeries on the wrong site or the wrong patient. “I hear about a couple of these every year,” added Dr. Shah.
Brian Nussenbaum, MD, execitive director of the American Board of Otolaryngology, explained that these wrong site/wrong patient errors are classified by the National Quality Forum as “never events.” Such errors in medical care are identifiable, preventable, and have serious consequences for patients. A closer examination of wrong-site surgeries reveals that they have several root causes. These could include hectic schedules, new teams, distractions, and a culture of hierarchy and fear.
Quality Improvement Initiatives
Dr. Nussenbaum described steps that hospitals can put in place to create a culture that reduces process errors. The first step is to identify all potential errors from scheduling and eliminate variation in the process of marking the correct surgical site. “These things aren’t always intuitive, even though you would think that they should be,” he said.
Another suggestion is to have the surgeon confirm, as part of the surgical briefing or time out before every surgery, that “all team members have introduced themselves by name and role,” noted Dr. Nussenbaum. “That sets the culture in the room.” Research has shown that by giving people a chance to say something, you give them the power to speak up, thereby activating their sense of participation. In addition to incorporating the hospital’s standard surgical safety checklist, another example of how to operationalize quality improvement is to create a “Stop the Line” policy that allows any team member to request clarification or to interrupt a process when they perceive that there is an immediate risk to patient or personnel safety. This policy reinforces the message that it is safe to “speak up.”
Some hospitals have also implemented more formal checklists designed to improve team communication and consistency and, hopefully, reduce complications. A standard checklist requires approximately four minutes to implement and can identify potential surgical problems. Research has shown, however, that an important part of implementing the checklist is the debriefing after the surgery, a part of the process that is commonly either omitted or not performed seriously.
The speakers concluded the session by noting that surgical results are infinitely complex and can be beyond the control of physicians. Despite this acknowledgement, surgical teams can put measures in place to mitigate risk. Knowing this makes it clear that surgical teams must implement quality improvement initiatives.
Dr. Pullen is a freelance medical writer based in Illinois.