Showing papers by "Atul A. Gawande published in 2008"

Bar-coding surgical sponges to improve safety: a randomized controlled trial.

Abstract: Objective: A randomized, controlled trial was performed to evaluate a computer-assisted method for counting sponges using a bar-code system. Background: Retained sponges are a rare and preventable problem but persist in surgery despite standardized protocols for counting. Technology that improves detection of counting errors could reduce risk to surgical patients. Methods: We performed a randomized controlled trial comparing a bar-coded sponge system with a traditional counting protocol in 300 general surgery operations. Observers monitored sponge and instrument counts and recorded all incidents of miscounted or misplaced sponges. Surgeons and operating room staff completed postoperative and end-of-study surveys evaluating the bar-code system. Results: The bar-code system detected significantly more counting discrepancies than the traditional protocol (32 vs. 13 discrepancies, P = 0.007). These discrepancies involved both misplaced sponges (21 vs. 12 sponges, P = 0.17) and miscounted sponges (11 vs. 1 sponge, P = 0.007). The system introduced new technical difficulties (2.04 per 1000 sponges) and increased the time spent counting sponges (5.3 vs. 2.4 minutes, P < 0.0001). In postoperative surveys, there was no difference in surgical teams' confidence that all sponges were accounted for, but they rated the counting process and team performance lower in operations randomized to the bar-code arm. By the end of the study, however, most providers found the system easy to use, felt confident in its ability to track sponges, and reported a positive effect on the counting process. Conclusions: Use of automated counting using bar-coded surgical sponges improved detection of miscounted and misplaced sponges and was well tolerated by surgical staff members.

The frequency and significance of discrepancies in the surgical count.

Abstract: Objective:To prospectively evaluate and accurately describe the rate and type of discrepancies encountered in the surgical count.Introduction:Despite near-universal implementation of manual counting protocols for surgical instruments and sponges, incidents of retained sponges and instruments (RSI) p

Does the Surgical Apgar Score measure intraoperative performance

Abstract: Objective:To evaluate whether Surgical Apgar Scores measure the relationship between intraoperative care and surgical outcomes.Summary Background Data:With preoperative risk-adjustment now well-developed, the role of intraoperative performance in surgical outcomes may be considered. We previously de

Surgery for Hyperparathyroidism in Image-Negative Patients

Abstract: Hypothesis Patients with primary hyperparathyroidism and negative preoperative localization imaging have a different outcome than patients with positive imaging. Design Prospective single-surgeon case series. Setting Referral center. Patients Forty-two patients with primary hyperparathyroidism, indications for surgery, and both cervical ultrasonographic results and technetium Tc 99m sestamibi nuclear images that were nonlocalizing over a 5- year span. Main Outcome Measures Extent of surgery required to produce cure; operative findings. Results Of 430 patients undergoing surgery for primary hyperparathyroidism, 351 underwent both ultrasonographic and sestamibi imaging. Among 351 patients, the imaging results of 42 patients did not show an adenoma, and these patients underwent cervical exploratory surgery. Of 42 patients, 41 were cured at a mean follow-up of 90 days; 1 patient underwent surgical reexploration and was cured by removal of a mediastinal adenoma. To achieve initial cure, 12 of 42 patients (28.6%) required partial thyroidectomy, 9 (21.4%) required partial thymectomy, 17 (40.5%) required paratracheal dissection to access or devascularize an obscure adenoma. Pathologic examination disclosed single adenoma in 26 of 42 patients (61.9%), parathyroid hyperplasia in 14 (33.3%), and double adenoma in 2 (4.8%). Conclusions Patients whose preoperative localization studies fail to localize solitary adenoma commonly require extensive surgery to cure hyperparathyroidism. Lack of localization may be a reasonable criterion on which to base referral of the patient to a high-volume medical center.

Beyond counting: current evidence on the problem of retaining foreign bodies in surgery?

Abstract: Retained foreign bodies (RFB) are a rare but devastating and preventable complication in surgery Despite an increasing body of literature over the last decade, it has been difficult even to accurately estimate how frequently these events occur An estimate based on claims data suggests the incidence is in the range of 1 in 9000 to 1 in 19000 The current approach to the prevention of RFB relies on a standardized counting protocol developed by the Association of PeriOperative Registered Nurses (AORN) and adapted in operating rooms (ORs) across the country The counting process is labor-intensive and has been shown to negatively affect case progression and team performance In addition, to date, there is no data regarding the accuracy or reliability of manual counting Despite this uncertainty regarding the limitations of the current approach, new technologies are being investigated as adjuncts to the manual counting protocol The 2 articles published in this issue of Annals of Surgery take an important step toward understanding the utility of our current approach to the prevention of RFB The paper by Egorova et al identifies cases involving count discrepancies through the hospital reporting system at a large academic institution and its affiliates By linking these reports to administrative data, they are able to estimate the rate of RFB as well as evaluate the ability of the counting protocol to detect RFB as they occur Finally, they provide the first cost analysis of miscounts and compare it with another approach, performing universal radiographs in the operating room There are several important points to highlight in this study First, the authors report a RFB rate of 1 in 7000 Most of the previous literature on this topic has been limited to cases that were identified by review of medico-legal cases Although this study reports a higher rate than those previously published in the literature, this is still likely an underestimate because it relies on voluntary reporting by practitioners Beyond just reporting the rate of RFB, the authors estimate the ability of the manual counting protocol to detect and prevent these events Most practitioners anecdotally lament the limitations of the manual count, but this is the first published estimate of its test characteristics: a sensitivity of 77% and specificity of 99% Because of the low rate of RFB, this correlates to a low positive predictive value; only 16% of discrepant counts was actually associated with a RFB, leading practitioners to frequently disregard the discrepancy or rely on routine postoperative imaging for further evaluations Disturbingly, they found that one-third of discrepant counts did not prompt an intraoperative x-ray despite this being the standard procedure at the study institution It is important to note, as the authors point out, that these estimates do not take into account the missing items that are identified on interim counts Previous literature reported that 88% of RFB were associated with a correct count; however, this is the first report of the likelihood of a RFB given a counting discrepancy They report a positive likelihood ratio of 113, meaning that the odds of a retained foreign body are increased 100 times if there is a persistent discrepancy between the initial and

Physicians and Execution — Highlights from a Discussion of Lethal Injection

Abstract: Foreword On January 14, 2008, the Journal hosted a videotaped roundtable discussion of the issues raised by Baze v. Rees, currently before the Supreme Court, that asks whether the three-drug protocol used to carry out the death penalty by lethal injection causes unnecessary pain and suffering in violation of the Constitutional ban on cruel and unusual punishment. Moderator Atul Gawande was joined by law professor Deborah Denno, anesthesiologist–ethicist Robert Truog, and anesthesiologist David Waisel. What follows are highlights of their discussion about lethal injection, the current protocol, possible alternatives, and the role of physicians and other health care professionals in putting convicted criminals to death. The video, along with a related reader poll and an interactive timeline, can be found at www.nejm.org. The Protocol Dr. David Waisel: The three-drug protocol is based on what was considered a normal induction of anesthesia when it was developed. [The first drug is] thiopental, also known as ...