Surgical Checklists, Reducing Malpractice and Saving Patient Lives

It is hard to imagine that experienced surgeons, anesthesiologists and nurses would need a checklist to avoid obvious mistakes in surgical procedures, but the hard evidence is that simple checklists make an enormous difference in patient outcomes. Complications and medical malpractice rates are cut dramatically. The evolution of the checklist is chronicled in a recent book by Boston surgeon Atul Gawande. books[1].jpg

In his book, The Checklist Manifesto (Metropoliltan Books 2009), Dr. Gawande, who practices at the Brigham & Women’s Hospital in Boston, points out that the average American has seven operations in his or her lifetime; that there are fifty million operations performed every year; and that there are “upwards of 150,000 deaths following surgery every year–more than three times the number of road fatalities.” And, research has shown, “at least half our deaths and complications are avoidable.”
Inspiration for the procedural checklists for surgery came from the airline industry, which has always used checklists for routine and emergency procedures. Thousands of hours are spent honing the lists so they are not overwhelmingly detailed and difficult to follow. And they work.
Working with the World Health Organization, Dr. Gawande and the research team studied complication rates in a variety of hospitals around the world, some teaching institutions in wealthy countries, some from the most impoverished countries, and some in between. Complications and deaths were assessed. The checklist was implemented and changes were studied. Within months, major complications had dropped by 35% and deaths had dropped by 47%.
The 19-point checklists now in use include some remarkably simple steps: The operating room personnel introduce themselves and state their roles; they discuss any known risk factors; they make sure they have the right patient, the right procedure, and the right part of the body. The list also includes more details such as confirming medication allergies, reviewing the anesthesia plan, discussing concerns about blood loss, identifying pathology specimens, confirming sponge and needle counts, and sending important information to the recovery room.
These simple procedures have saved lives, reduced complications, and saved probably hundreds of millions of dollars and immeasurable pain and suffering. A checklist that costs almost nothing to perform (just a few minutes of everybody’s time) is easily saving far more than any possible medical malpractice “reform” that is being considered in the halls of Congress or state houses around the country.  Further fine-tuning of medical practices, not punishing the injured, is the correct path to malpractice reform.
Advice to Consumers: If you are planning for a surgical procedure, make sure your surgical team is using a checklist to avoid complications in your case. According to Dr. Gawande, over 94% of medical professionals say they would want a checklist for themselves.

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Investigation Finds Hospital Staff Not Responding to Medical Alarms

Some 216 hospital deaths nationwide are being linked to problems with alarms on patient monitors and medical staff failing to respond, found a Boston Globe investigation.

The Globe analyzed the Food and Drug Administration’s database of adverse events involving medical devices from January 2005 to June 2010.

In many cases, the problem wasn’t defective medical alarms. The medical industry calls the problem, “alarm fatigue.” Hospitals are using more medical alarms than ever to monitor patients, all of which have different sounds and speeds depending on the severity of the physical symptom.

In one case, a 15-bed unit at John Hopkins Hospital in Baltimore, staff documented an average of 942 alarms per day – about one critical alarm every 90 seconds.

The result, hospital administrators say, is nurses have become desensitized to the constant beeping. And patient safety advocates say their medical negligence is resulting in patients suffering wrongful deaths, including in Massachusetts hospitals.

“Hospitals must establish a “zero tolerance” for patient injuries or deaths due to alarm errors or so-called “alarm fatigue,” according to Boston medical malpractice lawyer Marc Breakstone. “These devices save lives. They not only have to work, but the staff has to respond immediately when they sound. Anything less is unacceptable.”

One case dates back to September 2008 at Tobey Hospital in Wareham. An 87-year-old man was wearing a wireless heart monitor that started to weaken. He later died and a state investigation found his EKG displayed a flat line on a monitor at the nurses’ station for over two hours without a response.

Cases of medical negligence such as these are driving change at Massachusetts hospitals.

Southcoast Health System, which manages Tobey Hospital, is hiring nurses and giving them one assignment: responding and monitoring patient monitors. It has also established a policy that monitor batteries must be changed at a certain time each day.

At UMass Memorial Medical Center in Worcester, the hospital wants to eliminate unnecessary monitoring and has implemented new guidelines for when doctors should order cardiac monitoring. Among other changes, nurses are now receiving low-battery warnings about patients on their pagers and cell phones.

As hospitals make these changes, manufacturers are assessing their equipment and working on new “smart monitor” technology. Rather than measure just one symptom, the hope is these new monitors would assess multiple parts of the body before determining whether an alarm needs to sound. For its part, the Food and Drug Administration recently distributed videos about defective medical alarms and proper use to 4,500 hospitals and nursing homes.
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Massachusetts’ Zero Tolerance Policy in EMT Scandal Critical for Safety

The recent news that more than 200 EMTs in Massachusetts fraudulently obtained re-certification revealed serious safety lapses in the system. We applaud the state’s swift move to suspend the EMT licenses and call on the Department of Public Health (DPH) to closely monitor future re-certifications.

An anonymous caller tipped off DPH officials to the EMT scandal when she reported an EMT-paramedic for a private ambulance company had received re-certification without attending the required classes. When state officials investigated, they learned the fraud ran much deeper, touching more than 200 EMTs throughout the state.

The impacted fire departments include Haverhill, Boston, Lexington and Belmont among others. Haverhill had 30 EMT licenses suspended while Boston had 21.

The abuse was most rampant among private ambulance companies. Armstrong Ambulance of Arlington had 41 EMTs working with fraudulent certification while Trinity EMS had 35 EMTs and Cataldo Ambulance of Melrose had 46 EMTs, according to media reports. For Cataldo, the majority of the involved EMTs came from the company’s Atlantic Ambulance Service division on the North Shore.

The state suspended most of the EMT licenses for 90 days to nine months. Lexington firefighter Mark Culleton and former Trinity Ambulance paramedic Leo Nault, the instructors involved in the fraud, have been permanently banned from practicing in Massachusetts.

Emergency medical technicians in Massachusetts are required to undergo between 24 and 36 hours of retraining every two years. The training serves as a refresher course and updates EMTs on new medications, techniques and equipment.

“This ongoing training is critical for EMTs because they are called upon to make life and death medical decisions in the field,” said Boston medical malpractice lawyer Marc Breakstone. “The Department of Public Health must maintain a zero tolerance policy towards any fraud or misrepresentation regarding the training and qualifications of the front-line medical providers.”

In 2001, Breakstone negotiated a $10.2 million settlement for a Massachusetts family whose toddler was left severely brain-damaged by paramedic negligence. There were significant delays in the care. The ambulance crew got lost on the way to the home, forgot the keys to their medical cabinet and later falsified records in an attempt to hide the medical negligence. As a result of that case, the Massachusetts Department of Public Health established guidelines that made reporting of serious medical errors by EMTs mandatory.

For more information, see these articles from The Boston Globe: “Phone Tip Led to EMT Card Scam” and “State Officials Examining EMT Retraining System”
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