The importance of developing a safety culture
In the January 2017 issue of AAOS Now, my coauthor Robert J. MacArthur, MD, shared a first-person account of how a wrong-side knee procedure could occur in the era of Universal Protocol. I—David Ring, MD, PhD—also have a personal story of medical error.
In 2008, I published an account of my wrong procedure—a carpal tunnel release in a patient who should have had a trigger finger release—and later spoke about my error at several meetings across the country. One of the most inspiring aspects of my story is that my error occurred within a culture of safety. In a culture of safety, both the patient who is harmed and the team that is distraught over having caused that harm are cared for. The person or persons that contributed to the error are each recognized as having something to teach and a story to tell. In a culture of safety, a mistake is a reason to come together and an opportunity to learn and grow.
Unfortunately, like many others, Bob didn't have the good fortune to err in an institution with an effective safety culture. In the spirit of learning, I spoke with Bob about the aftermath of his error. He and I both hope that an open discussion of these issues will help build and enforce safety cultures throughout orthopaedic surgery.
Dr. Ring: Thanks so much for sharing your story, Bob; we learn so much from firsthand accounts of error. Tell us why you decided to come forward with the details of your story.
Dr. MacArthur: I first want to offer my support to providers who have performed wrong-site surgeries. I know personally how painful it is to harm a patient. To have a poor surgical outcome or complication is stressful, but to make a medical error like a wrong-site surgery is truly devastating. I don't come forward for sympathy. In fact, my primary emotion at this time, 8 years later, is one of guilt and sorrow for the emotional trauma I have caused my patient and my staff. I am telling my story to do what I can to keep this from happening to others and as a way of apologizing to the patient I hurt and the staff in my operating room whose careers were damaged.
Dr. Ring: What was the institution's response to the team involved with the error?
Dr. MacArthur: The day after I scoped the wrong knee I was informed that the hospital had fired the anesthesiologist. He had occasionally sparred with the administration over work conditions and compensation, but firing him under these circumstances reinforced a "blame and shame" culture. It sent a message that errors will be punished. I met with the anesthesiologist the day after my error and he was distraught. He explained that he would likely have to sell his home and move from the area. He had kids in middle and high school. I felt horrible. I attempted to find the circulating nurse and scrub nurse to offer my support and try to protect their jobs. I could never reach them. My understanding is that they were also let go.
Dr. Ring: What measures did you take to help ensure that a wrong-site procedure wouldn't happen again?
Dr. MacArthur: I met with one of our senior physicians to promote the Sign Your Site (SYS) protocol. Operating through my initials would have prevented my wrong procedure. I learned that two influential joint specialists had modified the protocol to allow someone to mark for them (so they could remain in surgery) and to avoid ink at the incision site because they felt it was "distracting." I was upset with the two joint specialists for prioritizing volume over safety, the chief of orthopaedics and the hospital administration for allowing these alterations to the policies, and myself because I did not adhere to the SYS protocol on my own initiative.
Dr. Ring: I also regretted not using the SYS protocol. I had known about it for years, always followed it when I did the marking, and often thought that I should not allow anyone else to sign for me or sign anything other than the incision site. My wrong procedure would have been prevented if I had routinely used SYS on my own initiative. Orthopaedic surgeons should always operate through their initials. Did anything positive follow your error?
Dr. MacArthur: I learned that the surgery center had experienced two wrong-site events in the 18 months prior to my error. After my event, the administration arranged for staff to attend mandatory safety training by a company affiliated with the airline industry. During the training lecture, several staff in the audience were surprisingly vocal in their opposition to the class, scolding the lecturer for wasting their time. I stood up and spoke about my error. I asked everyone to pay attention because my error was the center's third wrong-site surgery in an 18-month period. I then attended as many additional lectures as possible and told my story at each one.
Dr. Ring: In effect, you became a patient safety champion. I admire that. Did your efforts pay off?
Dr. MacArthur: On the contrary, that's when things took a turn for the worse. Patient referrals declined precipitously. Over the prior 5 years, the hospital had purchased the practices of most of the family practice, internal medicine, and pediatric physicians and thereby controlled the referral patterns of half the doctors who had been referring to me. There was no phone call—the referrals simply stopped. That was half of my practice.
In the hospital, the nurses would no longer take verbal orders from me at home, during off hours, insisting that I come in and sign in person. They started writing me up. The chief of orthopaedics informed me that, in his opinion, these complaints did not reflect faulty care or unprofessional behavior on my part, but were seemingly related to my wrong procedure. A floor nurse approached me and explained that the two joint specialists were upset that they now had to see their patients in the preoperative area and were bad-mouthing me to the nurses. I realized that continuing to work in this environment would be both stressful to me and dangerous for my patients. I began working at a hospital an hour away, but work was slow.
Dr. Ring: Among safety advocates, this response is called "blame and shame." Instead of seeing error as part of being human, a person who makes an error is often ostracized and treated as someone who is uniquely and irrecoverably flawed. I know that most healthcare facilities are trying to get away from these types of reactions and I'm thankful for it. Please continue with your story.
Dr. MacArthur: A lawsuit followed and was settled 2 years after the event. An additional year and a half later, I was notified by the Medical Board of California that I was under investigation for medical negligence. The investigator was concerned about another error of mine, an intraoperative burn from the hinge of a hot clamp that had been flash sterilized. This was my second "never event" in a 2-year period and gave the Board the impression that I was a reckless surgeon. The Joint Commission, the American Association of Operating Room Nurses, and the clamp manufacturer had all written clear guidelines against use of flash sterilization of this clamp, except during emergencies, due to burn risk from uneven heating of large instruments. During the surgery, the clamp did not feel hot and I was not aware of the flash sterilization or the risk of a burn from the clamp. As a result of this error, I advocated for a formal policy against flash sterilization.
In the midst of these difficulties, I was offered and accepted a salaried general orthopaedic position in a small underserved town in Texas. As a general orthopaedic surgeon with 15 years' experience, I thought my skills might be more valued in rural Texas than in Southern California, and I was hoping for a fresh start in a new setting.
While working in Texas under a provisional license, I was notified that the Texas Medical Board could not process my state license application until the California Medical Board had made a determination. Due to a dearth of investigators in California, it can be well over a year or two before an investigation is finished. I therefore moved my two sons back to California and worked in workers' compensation clinics while I waited for the investigation to conclude.
Four years after my wrong procedure I was formally charged with negligence, and 5 years and 3 months after my error, I was offered a hearing. The hearing judge explained that a trial could not start for at least another year or two, and that administrative judges had recommended 1 to 3 years of probation for wrong-site events in the past. Facing up to 5 years of potential uncertainty and probation, I decided to forego a trial and accept a 3-year probation, a decision that I regret. Immediately after probation started I was dropped from the Qualified Medical Examiner panel (a state-neutral workers' compensation panel) and several Preferred Provider Organizations. I have therefore been relegated to practicing in workers' compensation clinics until the end of my 3-year probation: 8 years and 6 months from the date of my error.
Dr. Ring: We need better systems for managing error and those of us who err. The best safety systems (eg, the airlines and manufacturing) expect error and create systems to catch it before it causes harm. People are encouraged to speak up. Open discussion of good catches and errors reminds everyone that it could happen to them, helps develop the best possible checklists and other safety systems, and helps medical staff value and work together on implementing these systems. I know that you have spent a great deal of time and energy learning about human error and wrong procedures in particular.
Dr. MacArthur: I wish wrong-site surgeries were no longer a national issue and that I had never performed one. Unfortunately, these events are still common.
Among the 160 Qualified Medical Examiner evaluations I performed prior to my probation, three patients had unreported wrong-site events. I requested data on medical errors from the California Department of Public Health and I contacted experts from two other states, representing 15 percent of the U.S. population. These databases contain a consistent incidence of 21 orthopaedic wrong-site surgeries a year. I found that 10 of the 388 reporting hospitals in California were responsible for more than 25 percent of all the adverse events. It seems to me that safety protocols could be enhanced by identifying high-risk hospitals in each state and intervening with education and methods to improve the safety culture within those facilities.
I believe that with a multifaceted approach, orthopaedic surgeons can significantly reduce the incidence of wrong-site surgery. I believe that, as a profession, we should do the following:
- Develop a centralized state and/or federal agency devoted entirely to medical safety. Comprehensive databases can identify the best opportunities for decreasing error and harm.
- Prioritize a strong safety culture in medicine, matching that of the airline industry.
- Improve and champion standardized protocols such as SYS and Universal Protocol. These are still not used routinely in many ambulatory surgery centers.
- Care for the "second victims," the providers whose error caused harm.
- Address human error with better safety systems, coach at-risk behavior, and limit punishment to reckless behavior.
Dr. Ring: Unfortunately, yours will not be the last wrong procedure, but I hope it's the last one that leads to such a demoralizing aftermath.
Dr. MacArthur: My hope is that my story has readers "scared aware." It's important to be cognizant of the risks of surgical error. If you are aware of stronger protocols than those used in your facilities, lead by example and use the strongest protocols on your own initiative and promote them among colleagues and leadership. The next time you make an error or catch an error you were about to make, I will support you, and I hope that you will openly and freely share your story so that we can improve patient and provider care.
Robert J. MacArthur, MD, is a California-based orthopaedic surgeon.
David Ring, MD, PhD, is chair of the AAOS Patient Safety Committee