tag:blogger.com,1999:blog-2760353953251845523.post7150074330625751308..comments2024-02-10T02:14:39.898-05:00Comments on Buckeye Surgeon: Gawande on the MatrixJeffrey Parks MD FACShttp://www.blogger.com/profile/15650563299849196122noreply@blogger.comBlogger7125tag:blogger.com,1999:blog-2760353953251845523.post-7990861694762154792010-06-22T15:25:13.104-04:002010-06-22T15:25:13.104-04:00Surgery/OB/everything else doesn't know what c...Surgery/OB/everything else doesn't know what can be prevented because there's no organized effort to conduct broad studies and make changes. What doctors mostly know about medical errors are the ones they've seen in their own practice, and that's too small a sample to draw any conclusions from. (You can see that I start with the premise that nearly all doctors are well-trained, conscientious and well-meaning!) Gawande mentions all the things you mention as helping to end anesthesia deaths, but those improvements didn't happen randomly. Random anesthesiologists didn't individually kill enough people over the course of their careers to make them change their patterns of practice. It took someone to study the causes of error and someone to champion broad changes to correct the errors. Someone has to create a culture in which safe practices -- like using pulse oximetry -- become standard.<br /><br />In our company, for instance, we identified vehicle accidents as a safety concern that could be fixed. Statistically, the most common accidents are backing accidents. They can also be extraordinarily damaging. Think of all the incidents you've read about in which someone accidentally backs over their own child in the driveway. So in our company, everyone who drives a company vehicle or is on company business is required to walk a full circle around the vehicle before backing. When you back your service vehicle out of the parking lot in the morning. When you go to a customer location and need to back out. When you go to lunch at a restaurant. It is NEVER all right to back your vehicle without making the circle.<br /> <br />Needless to say, it's a firing offense if you text while driving in a company vehicle or while on company business. You don't even have to have an accident; your boss just has to find out about it.<br /><br />Now, it's not that we ever had an unusual number of backing or texting accidents. Like everyone, we find lots of different ways to screw up. But if you want to eliminate accidents -- and we do -- you have to make people adopt safe habits and use them all the time. Maybe we'd only have one backing accident in a year if we didn't make everyone walk the circle. By requiring that walk, we eliminate that one accident. It's worthwhile. Like they used to say about millions of dollars, an accident here, an accident there, pretty soon it starts to add up.<br /><br />Before medical errors can be reduced, doctors have to accept the idea that they can be. That's a hard sell. (The benefits of having medical practitioners wash their hands before seeing patients have been known for centuries, yet some hospitals are still fighting that battle!) Doctors generally do a stupendous job, but there's room for improvement.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-2760353953251845523.post-1599139317326723332010-06-22T07:22:08.605-04:002010-06-22T07:22:08.605-04:00The Decreased Mortality in Anesthesia was due to
...The Decreased Mortality in Anesthesia was due to <br />1: Pulse Oximetry<br />2: End Tidal CO2 Monitoring<br />3: Connecting the O2 and Nitrous knobs so you can't turn the oxygen any lower than 250 ml/min<br />99% of the preventable deaths were unrecognized Esophageal Intubations. Surgery/OB/everything else doesn't have anything that simple to prevent.<br /><br /><br />FrankAnonymousnoreply@blogger.comtag:blogger.com,1999:blog-2760353953251845523.post-18129277142920715732010-06-21T15:21:12.641-04:002010-06-21T15:21:12.641-04:00I'm reading "Complications" right no...I'm reading "Complications" right now, and I think you and I are picking up different ideas from what Gawande is saying.<br /><br />I don't see Gawande calling for the individual doctor to give up responsibility or to be subsumed within a giant Medical System. I see him calling for a more systematic consideration of errors and how they can be fixed.<br /><br />Back in the 70s, Lockheed had a quality control program called Zero Defects. They honest-to-God aimed to turn out airplanes -- complex, combat-ready airplanes comprising millions of parts -- with absolutely nothing wrong with them. They put together study groups, committees and research projects to look into everything that went into building a plane, trying to make the process foolproof every time. I don't know how well they succeeded, but I know there are plenty of C141s, C130s and C5As from that era still in service today.<br /><br />I work for a cellphone company allied to several power companies. Many people in the power companies have dangerous jobs. They work with high voltage electric currents. They climb power poles. They drive hundreds of miles per day on their inspection routes. Even in my company, there are dangerous jobs. The guys who maintain our equipment have a lot to contend with under the best of circumstances. But they're needed most when the cicrumstances are worst; they sometimes have to get police escorts to take them into areas that are being evacuated because a hurricane is coming. The power crews will be out in force when the hurricane moves out, and all of them will need to use our system to communicate, so our guys have to install extra equipment before the hurricane arrives.<br /><br />Accidents are inevitable when you work in an environment like this, with a lot of people who do things that are inherently unsafe. But a few years ago the top management in our companies looked at both the economic and human costs of accidents and decided we needed to do something. They began a program to reduce our accident rate to zero. They formed committees to figure out how to make jobs safer -- more training, better equipment, more emphasis on safe procedures. Safety became a factor in our annual bonuses. As you would guess, vehicle accidents are a concern, and they rose to a crisis level when a van full of power company employees on the way home from work got into an accident a little more than a year ago. Another driver failed to maintain his lane and clipped the van; the van rolled over and several employees were killed. Although the driver of the van was in no way at fault, management promptly enrolled every employee in all our companies in a defensive driving course. Everyone whose job involves significant driving had to take a road course; those of us with office jobs took the course online.<br /><br />Although this emphasis on safety sometimes descends to the level of mere cheerleading, although it has cost the company a lot of money and although some of the measures it has led to are a hassle, you can't argue with the results. My particular company has now gone 613 days without a reportable accident. Our previous best was 276 days. Results for the power companies aren't quite as good because the power companies are bigger, but even there the emphasis on safety has reduced accidents to a place where they are rare. And let me point out that none of this has in any way reduced the level of responsibility of our employees or reduced the level of complexity of our jobs.<br /><br />Medical errors are dangerous, relatively common, and could be prevented if doctors would get behind an effort like this. In "Complications," Gawande describes how anesthesiologists, in a single decade, reduced the number of anesthesia-related deaths to 1/20th of what they had been. Imagine the savings in money, lives and suffering if every medical specialty would do the same. That's what I hear Gawande calling for.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-2760353953251845523.post-10814892447534626282010-06-21T14:05:59.862-04:002010-06-21T14:05:59.862-04:00I agree!
Buckeye, an entire generation is coming...I agree! <br /><br />Buckeye, an entire generation is coming up having had no personal responsibility and expecting to have none. You get kind of tired constantly being the one to grab that basketball before it rolls off the court. You can throw it back in to one of the "team" but more often that person will just stand there and let the ball hit them rather than catch it... then you get accused of changing the game to dodgeball just because you naturally start to throw that ball a little harder :o)<br /><br />-SCRNAnonymousnoreply@blogger.comtag:blogger.com,1999:blog-2760353953251845523.post-21030407842251705782010-06-21T11:57:14.418-04:002010-06-21T11:57:14.418-04:00Yes, I think much of the message of the graduation...Yes, I think much of the message of the graduation address was "the notion of an individual physician taking care of an individual patient and being responsible for that care is sooo last year's approach." I am amazed and gratified that a surgeon younger than 40 years shares some common values with a retired doc who began practice at a time when no one even questioned the primacy of the fiduciary duty of the physician to the patient and physician responsibility and no one blamed a screw up on a system failure.james gaultehttps://www.blogger.com/profile/05537303135780186926noreply@blogger.comtag:blogger.com,1999:blog-2760353953251845523.post-83834511314021812722010-06-21T00:12:11.493-04:002010-06-21T00:12:11.493-04:00Can I just say how much I adore you?
When i read t...Can I just say how much I adore you?<br />When i read this post, I'm thinking "yes, this is exactly what I think or how I feel' but I would never be able to articulate it even one tenth as well as you do. For the most part, it's still somewhere in my brain in a shapeless magma...<br />And yes, it makes me seethe that 99.9% of the time, this whole "team" concept translates onto no one taking responsibility for anything.Emmanuellenoreply@blogger.comtag:blogger.com,1999:blog-2760353953251845523.post-26782012003405862562010-06-20T21:03:47.936-04:002010-06-20T21:03:47.936-04:00This is what I don't understand about people w...This is what I don't understand about people who devote themselves so entirely to the idea that medical science and evidence based medicine is ALWAYS going to be best option and is ALWAYS right. Because even the most recent medical history doesn't support it at all. People thought there was no way bacteria could live in the stomach and cause ulcers. Remember intensive insulin control? - first it was good, now its bad. Or Xigris? And what about all of these 'never' events that actually seem to happen a few times in all studies regardless if everyone did everything possible to prevent them. 'Evidence-based medicine' is like a Garmin GPS for your car - its good to have, it generally does a good job, but every once in a while it drives you to the projects when you're trying to go to dinner at a colleague's house. That's why there's a person with a brain who is capable of synthesizing all of the real-time data before him/her that is actually navigating the car and can thus determine that things actually don't look quite right. This is somewhat akin to the difficult role the modern doctor must assume, and that's where your call for personal responsibility comes in, and I think it can't be echoed enough. I wonder how much 'in the trenches' patient care someone who thinks otherwise is actually doing, because it sounds much more like the words of a hospital administrator than a busy practicing physician.Joshnoreply@blogger.com