Showing papers by "Atul A. Gawande published in 2003"

Improving safety with information technology.

Abstract: Information technology can improve patient safety by preventing errors and facilitating rapid response to adverse events. Computerized prescribing by physicians reduces the rate of medication-related errors. Systems that automatically page clinicians about serious laboratory abnormalities and remote monitoring of patients in intensive care units also appear promising.

Risk Factors for Retained Instruments and Sponges after Surgery

Abstract: Background Risk factors for medical errors remain poorly understood. We performed a case–control study of retained foreign bodies in surgical patients in order to identify risk factors for this type of error. Methods We reviewed the medical records associated with all claims or incident reports of a retained surgical sponge or instrument filed between 1985 and 2001 with a large malpractice insurer representing one third of the physicians in Massachusetts. For each case, we identified an average of four randomly selected controls who underwent the same type of operation during the same six-month period. Results Our study included 54 patients with a total of 61 retained foreign bodies (of which 69 percent were sponges and 31 percent instruments) and 235 control patients. Thirty-seven of the patients with retained foreign bodies (69 percent) required reoperation, and one died. Patients with retained foreign bodies were more likely than controls to have had emergency surgery (33 percent vs. 7 percent, P<0.001...

Risk factors for retained instruments and sponges after surgery

Abstract: This case-control study was conducted to investigate the factors that lead to retained instruments and sponges during surgery. Cases were identified from the records of a large malpractice insurer in Massachusetts. All ofthe claims or incident reports of retained surgical sponges or instruments for the years 1985 to 2001 were included. Control cases were randomly selected from patients identified in hospital records of patients who had undergone the same operative procedure. Four controls were selected for each case. In the 15 years of the study period, there were 54 confirmed instances of a foreign body retained after surgery (total number of objects, 61). Most objects (54%) were left in the abdominal or pelvic cavity, 22% were left in the vagina, 7.4% in the thorax, and 17% in the spinal canal, face, brain, or extremities. In more than two thirds of cases (69%), the object retained was a surgical sponge. More than one sponge was retained in 7% of the cases, a clamp was left in 7%, and other objects, such as a retractor or electrode, were retained in 24%. At the major reporting hospitals included in the insurance company records, the rate of retained foreign bodies ranged from 1 per 8801 to 1 per 18,760 surgeries. The time to detection of the foreign body varied from the day of surgery to 6.5 years, with a median 21 days to detection. Three (6%) cases were identified on the day of surgery, and 14 (26%) were not detected until 60 days or more after surgery. Radiography or computed tomography was the usual method of detection (69%), but detection was made by physical examination or self-examination in 25% of the cases. In 9% of patients, the object was discovered incidentally during reoperation. Sixty-nine percent of the patients required surgery for removal of the foreign body and treatment of the resulting complications. Twelve of these retained objects led to small-bowel complications, including fistulae, obstruction, or visceral perforation. There was one death among these patients. When the cases and their matched controls were evaluated by univariate analyses, emergency surgery, unexpected change in procedure, involvement of more than one surgical team, and failure to perform a count of sponges and instruments were all associated with a higher rate of retained foreign body. No association was seen for age, duration or lateness of the operation, or the performance of multiple procedures. With multivariate analysis, three variables that posed a significantly higher risk of a retained object were identified: emergency procedure (risk ratio, 8.8; P <.001), unplanned change in procedure (risk ratio, 4.1; P <.01), and body mass index of the patient (risk ratio for each one-unit increase, 1.1; P <.01). Failure to perform a count of sponges and instruments had a strong association with emergency surgery but did not retain individual significance. Forty-seven claims involved litigation and resulted in an average of $52,581 in costs for compensation and legal-defense expenses.

Femtosecond laser-tissue interactions: Retinal injury studies

Abstract: We report the first study of laser-tissue interaction in the femtosecond time regime. Retinal damage thresholds and mechanisms produced by exposure to high-intensity femtosecond laser pulses were investigated in chinchilla grey rabbits. Exposures were performed using single laser pulses of 80 fs duration at 625 nm. ED 50 injury thresholds of 0.75 and 4.5 μJ were measured using fluorescein angiographic and ophthalmoscopic visibility criteria evaluating 204 laser exposures. Ultrastructural studies including light and electron microscopy were performed on selected lesions. Results suggest that the primary energy deposition in the retina occurs in melanin, However, in contrast to laser injuries produced by longer pulses, exposures of more than 100 × threshold in the 50-100 \mu J range did not produce significantly more severe lesions or hemorrhage. This suggests the presence of a nonlinear damage limiting mechanics in tissue exposed to femtosecond laser pulses.

Dispatch from India

Abstract: The puzzle was how the surgeons in India do it. Take a town like Nanded, 400 miles east of Mumbai (as Bombay is now called), in the center of India. The public hospital in Nanded serves a district of 1400 villages and 2.3 million people. It has 500 beds, three operating rooms and, I found when I visited, just nine general surgeons. (Think Washington, D.C., with just nine surgeons.) Its two main buildings are four stories high and made of cement and stucco. Surgeons arrive each morning to a crush of several hundred people pressing their way into the clinics. . . .