Showing papers by "Atul A. Gawande published in 2007"

Patterns of Communication Breakdowns Resulting in Injury to Surgical Patients

Abstract: Background Communication breakdowns are a common threat to surgical safety, but there are little data to guide initiatives to improve communication. Study design In surgeon-review of 444 surgical malpractice claims from 4 liability insurers, we identified 60 cases involving communication breakdowns resulting in harm to patients. Two surgeon-reviewers analyzed these cases to identify common characteristics and associated factors. Based on identified patterns, potential interventions to prevent communication breakdowns were developed and their potential impact was assessed. Results The 60 cases involved 81 communication breakdowns, occurring in the preoperative (38%), intraoperative (30%), and postoperative periods (32%). Seventy-two percent of cases involved one communication breakdown. The majority of breakdowns were verbal communications (92%) involving 1 transmitter and 1 receiver (64%). Attending surgeons were the most common team member involved. Status asymmetry (74%) and ambiguity about responsibilities (73%) were commonly associated factors. Forty-three percent of communication breakdowns occurred with handoffs and 39% with transfers in the patient's location. The most common communication breakdowns involved residents failing to notify the attending surgeon of critical events and a failure of attending-to-attending handoffs. Proposed interventions could prevent 45% to 73% of communication breakdowns in this cases series. Conclusions Serious communication breakdowns occur across the continuum of care, typically result from a failure in verbal communication between a surgical attending and another caregiver, and often involve ambiguity about responsibilities. Interventions to prevent these breakdowns should involve: defined triggers that mandate communication with an attending surgeon; structured handoffs and transfer protocols; and standard use of read-backs.

Long-term assessment of a multidisciplinary approach to thyroid nodule diagnostic evaluation

Abstract: BACKGROUND. The diagnostic evaluation of patients with thyroid nodules is imprecise. Despite the benefits of fine-needle aspiration (FNA), most patients who are referred for surgery because of abnormal cytology prove to have benign disease. Recent technologic and procedural advances suggest that this shortcoming can be mitigated, although few data confirm this benefit in unselected patients. METHODS. A total of 2587 sequential patients were evaluated by thyroid ultrasound and were offered ultrasound-guided FNA (UG-FNA) of all thyroid nodules that measured � 1 cm during a 10-year period. Results of aspiration cytology were correlated with histologic findings. The prevalence of thyroid cancer in all patients and in those who underwent surgery was determined. Surgical risk was calculated. RESULTS. Tumors that measured � 1 cm were present in 14% of patients: Fortythree percent of patients had tumors that measured \2 cm in greatest dimension, and 93% had American Joint Committee on Cancer stage I or II disease. The cytologic diagnoses ‘positive for malignancy’ and ‘no malignant cells’ were 97% predictive and 99.7% predictive, respectively. Repeat FNA of initial insufficient aspirates, as well as more detailed classification of inconclusive aspirates, improved preoperative assessment of cancer risk and reduced surgical intervention. Fifty-six percent of patients who were referred for surgery because of abnormal cytology had cancer compared with from 10% to 45% of patients historically. An analysis of operative complications from a subset of 296 patients demonstrated a 1% risk of permanent surgical complications. CONCLUSIONS. The current findings demonstrated the benefits of UG-FNA and of a more detailed classification of inconclusive aspirates in the preoperative risk assessment of thyroid nodules, supporting adherence to recently published guidelines. Cancer (Cancer Cytopathol) 2007;111:508–16. a 2007 American Cancer Society.

An Apgar score for surgery.

Abstract: Background Surgical teams have not had a routine, reliable measure of patient condition at the end of an operation. We aimed to develop an Apgar score for the field of surgery, an outcomes score that teams could calculate at the end of any general or vascular surgical procedure to accurately grade a patient's condition and chances of major complications or death. Study design We derived our surgical score in a retrospective analysis of data from medical records and the National Surgical Quality Improvement Program for 303 randomly selected patients undergoing colectomy at Brigham and Women's Hospital, Boston. The primary outcomes measure was incidence of major complication or death within 30 days of operation. We validated the score in two prospective, randomly selected cohorts: 102 colectomy patients and 767 patients undergoing general or vascular operations at the same institution. Results A 10-point score based on a patient's estimated amount of blood loss, lowest heart rate, and lowest mean arterial pressure during general or vascular operations was significantly associated with major complications or death within 30 days (p Conclusions A simple score based on blood loss, heart rate, and blood pressure can be useful in rating the condition of patients after general or vascular operations.

Patterns of technical error among surgical malpractice claims: an analysis of strategies to prevent injury to surgical patients.

Abstract: Objective: To identify the most prevalent patterns of technical errors in surgery, and evaluate commonly recommended interventions in light of these patterns. Summary Background Data: The majority of surgical adverse events involve technical errors, but little is known about the nature and causes of these events. We examined characteristics of technical errors and common contributing factors among closed surgical malpractice claims. Methods: Surgeon reviewers analyzed 444 randomly sampled surgical malpractice claims from four liability insurers. Among 258 claims in which injuries due to error were detected, 52% (n 133) involved technical errors. These technical errors were further analyzed with a structured review instrument designed by qualitative content analysis. Results: Forty-nine percent of the technical errors caused permanent disability; an additional 16% resulted in death. Two-thirds (65%) of the technical errors were linked to manual error, 9% to errors in judgment, and 26% to both manual and judgment error. A minority of technical errors involved advanced procedures requiring special training (“index operations”; 16%), surgeons inexperienced with the task (14%), or poorly supervised residents (9%). The majority involved experienced surgeons (73%), and occurred in routine, rather than index, operations (84%). Patient-related complexities— including emergencies, difficult or unexpected anatomy, and previous surgery— contributed to 61% of technical errors, and technology or systems failures contributed to 21%. Conclusions: Most technical errors occur in routine operations with experienced surgeons, under conditions of increased patient complexity or systems failure. Commonly recommended interventions, including restricting high-complexity operations to experienced surgeons, additional training for inexperienced surgeons, and stricter supervision of trainees, are likely to address only a minority of technical errors. Surgical safety research should instead focus on improving decision-making and performance in routine operations for complex patients and circumstances. (Ann Surg 2007;246: 705–711)

Disclosure Of Medical Injury To Patients: An Improbable Risk Management Strategy

Abstract: Pressure mounts on physicians and hospitals to disclose adverse outcomes of care to patients. Although such transparency diverges from traditional risk management strategy, recent commentary has suggested that disclosure will actually reduce providers’ liability exposure. We tested this theory by modeling the litigation consequences of disclosure. We found that forecasts of reduced litigation volume or cost do not withstand close scrutiny. A policy question more pressing than whether moving toward routine disclosure will expand litigation is the question of how large such an expansion might be.

Lag time in an incident reporting system at a university hospital in Japan

Abstract: Background: Delays and underreporting limit the success of hospital incident reporting systems, but little is known about the causes or implications of delayed reporting. Setting and methods: The authors examined 6880 incident reports filed by physicians and nurses for three years at a national university hospital in Japan and evaluated the lag time between each incident and the submission of a report. Results: Although physicians and nurses reported nearly equal numbers of events resulting in major injury (32 v 31), physicians reported far fewer minor incidents (430 v 6387) and far fewer incidents overall (462 v 6418). In univariate analyses, lag time was significantly longer for physicians than nurses (3.79 v 2.20 days; p<0.001). In multivariate analysis, physicians had adjusted reporting lag time 75% longer than nurses (p<0.001) and lag time for major injuries was 18% shorter than for minor injuries (p = 0.011). Adjusted lag time in 2002 and 2004 were 34% longer than in 2003 (p<0.001). Conclusions: Physicians report fewer incidents than nurses and take longer to report them. Quantitative evaluation of lag time may facilitate improvements in incident reporting systems by distinguishing institutional obstacles to physician reporting from physicians’ lesser willingness to report.

The way we age now: medicine has increased the ranks of the elderly. Can it make old age any easier?

Abstract: he hardest substance in the human body is the white enamel of the teeth. With age, it wears away nonetheless, allowing the softer, darker layers underneath to show through. Meanwhile, the blood supply to the pulp and the roots of the teeth atrophies, and the flow of saliva diminishes; the gums tend to become inflamed and pull away from the teeth, exposing the base, making them unstable and elongating their appearance, especially the lower ones. Experts say they can gauge a person’s age to within five years from the examination of a single tooth—if the person has any teeth left to examine. Scrupulous dental care can help avert tooth loss, but growing old gets in the way. Arthritis, tremors, and small strokes, for example, make it difficult to brush and floss, and, because nerves become less sensitive with age, people may not realize that they have cavity and gum problems until it’s too late. In the course of a normal lifetime, the muscles of the jaw lose about forty per cent of their mass and the bones of the mandible lose about twenty per cent, becoming porous and weak. The ability to chew declines, and people shift to softer foods, which are generally higher in fermentable carbohydrates and more likely to cause cavities. By the age of sixty, Americans have lost, on average, a third of their teeth. After eighty-five, almost forty per cent have no teeth at all. Even as our bones and teeth soften, the rest of our body hardens. Blood vessels, joints, the muscle and valves of the heart, and even the lungs pick up substantial deposits of calcium and turn stiff. Under a microscope, the vessels and soft tissues display the same form of calcium that you find in bone. When you reach inside an elderly patient during surgery, the aorta and other major vessels often feel crunchy under your fingers. A recent study has found that Annals of Medicine: The Way We Age Now: Reporting & Essay... http://www.newyorker.com/reporting/2007/04/30/070430fa_fac...

Disclosure of Medical Injury to Patients: An Improbable Risk Management Strategy

Abstract: Pressure is increasing for physicians and hospitals to be more open with patients about medical errors and adverse events. An oft-heard view in policy discussions is that fuller disclosure will reduce malpractice litigation, because many patients will come to understand that their injury was not due to negligence, or will feel less anger towards a provider who deals with them honestly. Additionally, some patients who do sue may be willing to settle their claims for less money. However, two lines of research suggest that disclosure may also prompt some patients to sue: the vast majority of patients who sustain medical injury currently do not sue; and an important reason why aggrieved persons do not seek legal redress is that they fail to recognize their condition or attribute it to an external cause. We modeled the litigation consequences of disclosure by combining existing data on the epidemiology of medical injuries and malpractice claims with expert opinion about likely patient reactions to disclosure. We used Monte Carlo simulations to incorporate uncertainty around the experts' judgments of the proportion of patients who would be prompted to sue and the proportion who would be deterred from suing. The model computed a 5% chance that total claim volume would decrease or remain unchanged and a 95% chance that it would increase. The distribution also indicated a 60% chance that comprehensive disclosure of severe injuries would at least double the annual number of claims nationwide, and a 33% chance that volume would increase by threefold or more. Under the assumption that average payments would not change, the model predicted a 6% chance that total direct costs of compensation would decrease or remain unchanged under routine disclosure and a 94% chance that they would increase. Under the assumption that disclosure reduced average payments by 40%, a net increase in costs remained more likely than a decrease or no change, and there was a 34% chance that costs would at least double. We found that under nearly any set of assumptions, the chances that disclosure would decrease either the frequency or cost of malpractice litigation were remote. An increase in the number and costs of claims was highly likely. The key driver of the model's findings is the well-established fact that only a tiny proportion of seriously injured patients sue, creating a huge reservoir of potential claims. An e-print of the paper is available from the first or second author.