HPH NOWBedside Ingenuity Needed to Prevent Medical Errors, Suggests Gawande
Atul Gawande, MD, MPH, recalls the satisfaction he felt after one of his first patients, a man with severe bleeding from the spleen, survived and was about to be discharged. But, then the man developed a deep wound infection from a resistant hospital bacterium, went into septic shock, and remained hospitalized for another month.
"After all the work we had done, he had picked up an infection because someone hadn't washed their hands," suggested Gawande, an associate professor in the HSPH Department of Health Policy and Management. "That someone" could have been him, he added. Gawande spoke on "Ineptitude: The Effect of Increasing Complexity in Medicine" at the Medical Grand Rounds series at Children's Hospital Boston on April 16.
Medicine is the most complex and most ambitious endeavor that humans have ever attempted, said Gawande, who is also an associate professor of surgery at Brigham and Women's Hospital.
Using science and know-how accumulated over centuries, doctors try to distill medicine, sort out inconsistencies, and customize it for individual patients, he said, adding that doctors promise to do this for every one of 300 million people in the country, not to mention everyone in the world.
But there are thousands of diagnoses described in medical books, as well as thousands of medical procedures, he noted. Each involves scores of steps now recognized to be required for successful outcomes. Not surprisingly, he said, "Now our struggle is with performance. There is a wide variability in the performance of care throughout the country."
Preventing medical errors and failures in performance is a crusade for Gawande, who is also the author of two acclaimed books, Complications: A Surgeon's Notes on an Imperfect Science and Better: A Surgeon's Notes on Performance. He's been a staff writer for the New Yorker since 1998 and received a MacArthur "Genius" Award in 2006.
He described an example of what can be accomplished through simply observing patterns of health care and then developing ways to address weaknesses. During the current war in Iraq, military physicians have dramatically reduced death rates on the battlefield — but not because of new technology. Instead, doctors have analyzed reports on injuries and outcomes and have detected problem patterns that might be reversed. The doctors discerned, for example, that soldiers were not wearing their chest armor and that transport times of the injured took too long. The doctors adapted their procedures to cope with those problems and have achieved an unprecedented wartime survival rate.
"This happened only because of their willingness to look at failure," Gawande asserted.
Similarly, he said, hospitals in the U.S. need to:
- monitor trends in performance, such as hospital-acquired infection rates and surgical complications
- analyze results regularly to assess progress
- engage in "bedside ingenuity" to develop solutions
One example of bedside ingenuity pioneered by Gawande was to employ bar codes to track sponges used in surgeries in an attempt to end the vexing and dangerous problem of sponges left behind inside patients. In a recent Annals of Surgery paper, Gawande and colleagues reported the results of a randomized clinical trial that evaluated a computer-assisted method for counting sponges. When compared to traditional counting methods, the automated, bar-coded system was better at detecting miscounted and misplaced sponges.
Another example of bedside ingenuity has been the use of checklists by health care providers. Gawande cited the example of a simple five-step checklist devised by Johns Hopkins researchers to reduce catheter-related infections. The researchers partnered with more than 100 hospitals in Michigan. They documented infection rates in ICUs prior to the use of checklists compared to rates during the use of checklists. The effort was associated with a decrease of two-thirds in the rate of bloodstream infections introduced by IV central lines.
The federal government suspended the study — a decision Gawande strongly criticized — because officials questioned whether the checklist had received ethics approval at each hospital involved as per regulations regarding human research studies, despite the fact that the research comprised a method of ensuring proven standard of care. This past February, the government announced that it would allow the study to resume. Citing the effort's benefits, the Department of Health and Human Services is now encouraging hospitals nationwide to adopt the approach.
Gawande, who has been a vocal advocate for checklists, is working currently with the World Health Organization on an effort to introduce surgical safety checklists worldwide. He described the effort in a New York Times Op/Ed in December 2007.
"We have shifted from a world in the past where our lives were governed by ignorance to a struggle now to make sure that what we have discovered about how to help and potentially cure people is actually executed," Gawande said.
—Ellen Barlow. Photo from iStockphoto.com/Bart Sadowski.