Small Changes, Stark Differences: Errors in Otolaryngology

The team ultimately recommended that small changes could be taken in medical-surgical practices-changes that would be relatively inexpensive but could have a big effect on outcomes. How big an effect? That’s hard to say, said Dr. Shah. Systems research points to this all the time. You have no way to realize the significance of making a small change until you actually make it.9

A clear example of this is one Dr. Shah and his colleagues frequently mention in their lectures and presentations. As reported in 2004 in Laryngoscope,10 when they looked at error classification, we found the type of medication errors that everyone always talks about, he said.

One of the more common errors was with the use of concentrated epinephrine on the operative field. The well-publicized case that occurred in Florida and was reported at the first national conference on medical errors in 1996, in which a surgical team inadvertently injected a young boy with concentrated epinephrine at a dilution of 1:1000, two orders of magnitude higher than was appropriate, is well familiar to otolaryngologists. The child died on the operating table.

That really caught the media’s attention, said Dr. Shah, but when otolaryngologists heard about the case, they considered it an anomaly, something that cannot happen in my practice.14 Yet when we did our study, we saw that five out of eight errors in the category of wrong drug/dilution on the surgical field involved concentrated epinephrine.

The upshot of this was that the investigative team approached the Boston Children’s Hospital administration and recommended that vials of concentrated epinephrine not be allowed in the operating room. And they said okay, Dr. Shah said. That’s a simple solution that has huge ramifications. We had never had an incident in our hospital with concentrated epinephrine in the operating room, but we took a proactive, prophylactic measure to ensure that it would not happen in the future.

Stark Differences

The Boston team’s research showed two major findings. The first was that although there were similarities between primary care and otolaryngology regarding the errors that occur, there were also stark differences, which in effect reflect the overall differences between medical and surgical practice.

About 20 percent of the errors that we reported were surgical errors, said Dr. Shah. Those were technical errors, he said, adding that a taxonomy that would work for a medical specialty such as family practice would not be able to catch those types of errors. We had a lower rate of medication errors, and that doesn’t mean we’re [more proficient in that area], it just means we use [and prescribe] less medication, he said. As an otolaryngologist, I feel comfortable saying that 90 percent of what we prescribe is about the same 15 medications or fewer, whereas family practitioners could prescribe 50 different medications a day, so they have a higher chance of having more errors with that. Data that appeared more frequently in the survey responses reflected errors in diagnosis, delayed treatment, surgery, communication, and administration.