Published 3/1/2011

Readers are concerned about patient safety

I’m deeply concerned by the many problems in the United States with relation to wrong surgery. Wrong surgery is an international health problem, one that is being addressed around the world.

In my opinion, the human factor is the key. I have the impression that there is too much transferring of the patient’s care from one provider to another. This results in a long chain of responsibility and can lead to problems.

In my department, over the past 22 years and more than 35,000 operations, we have had only ONE case (0.0028 percent) of a wrong surgical site—and that was limited only to the skin incision.

Our protocol is simple and effective. Every single patient who is admitted for an operation must be evaluated by the surgeon who will perform the operation. This rule is mandatory.

The surgeon establishes the diagnosis and surgical protocol. The surgeon discusses the case with the head of the department and other colleagues. The surgical site is well documented with both clinical and imaging studies and is clearly stated in the patient’s file.

Only the surgeon manages the patient’s care. The afternoon before surgery, the surgeon must once more evaluate the patient.

The white boards in the staff room and at the surgical theatre are marked with exactly the same data: name of patient, room, type of surgery. As the operating theatre is prepared, the team asks, “What patient? Which surgery? Which part?” In addition, the anesthesiologist, who also has exactly the same list, asks, “What patient? Which surgery? Which part?” for professional reasons.

This protocol is very simple and very effective. Too many interfaces with the patient by people other than the surgeon are inefficient and can generate many problems.

Remus Caranfil, MD
Piatra Neamt, Romania

Editor’s response: You are to be congratulated on your low incidence of wrong-site surgery. The incidence of wrong-site surgery has not decreased in the United States, in part because the universal protocol has brought about better and increased reporting. Once this number plateaus, I believe we will see a decrease in the incidence of wrong-site surgery.

In a perfect world, one patient/one physician would be ideal, but often that is not practical in the United States and support staff is necessary. You mention the human factor, besides just signing your site. The universal protocol addresses this the same way you do, with a “time-out” so the surgeon, anesthesiologist, and nursing team can verify the correct patient and the correct site, among other things. Most hospitals here have been using “white boards” for many years and now have adopted the extra measure of adding the universal protocol and signing your site. Thank you for your interest and your success.

The situation described in the Orthopaedic Risk Manager article “You be the Jury” (AAOS Now, December 2010) should not be ignored.The general circumstances regarding this patient’s condition and postoperative care occur frequently and occasionally lead to devastating results.

The outcome described (death from pulmonary embolism following outpatient knee surgery) could have been avoided by appropriate patient education as well as better communication between the doctor and patient on the potential coagulation complications and the available preventive measures.

All too often, patients are immobilized without appreciating simple techniques and exercises that can help avoid coagulation abnormalities. In this situation, because of the patient’s relevant past medical history, such education would have had even greater significance.

Let us learn from the experience of this doctor. I believe it is the responsibility of the orthopaedic surgeon or a qualified assistant to provide appropriate postoperative education in such detail that it actually can make a difference. Had this patient been given postoperative education, I am sure the history of his previous blood clot would have come up and appropriate anticoagulation therapy provided.

Let us act upon the deficiencies that are seen here and improve the quality of care to our patients. We have a responsibility to our patients to provide the best care possible and minimize the risks of postoperative complications. This must involve better education and communication to alert patients to potentially serious complications. Let’s raise the bar, be better doctors, and save lives.

Gary L. Painter, MD
Lorna Linda, Calif.

I read with interest the wise comments of James H. Herndon, MD, during the panel discussion on “What progress in patient safety?”. I thought it was very courageous of Dr. Herndon to give “the medical profession, our healthcare system, and orthopaedic surgeons a C minus.” I would probably have given a lower grade.

Dr. Herndon added, while discussing wrong-side surgery, that “studies show providers are performing inadequate patient histories and physical exams, failing to order appropriate tests, and developing insufficient follow-up care plans.” Although I agree that such factors have played a role in the creation of the unhappy condition [of our healthcare system], I suspect they are relatively unimportant when compared with the epidemic of prescribing nonessential tests, performing unnecessary surgeries, and abusing physical and occupational therapy under the fallacious excuse of “defensive medicine.”

I congratulate Dr. Herndon for his willingness to speak up and for his efforts to convince the orthopaedic community to do the right thing.

Augusto Sarmiento, MD
Miami, Fla.

Setting Now straight
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