Turn problems into pearls that help patients
Robert L. Brooks, MD, PhD
Physicians who are committed to preventing accidental harm to their patients realize the complexity of the task. The human body is, after all, neither a machine nor a factory. Biologic diversity results in more unpredictable responses than those found in industry.
All of us have experienced unexpected adverse events in patient care. Even more frequently, we experience those “almost” or “near-miss” events that are caught before harm occurs. The principles of patient safety challenge us to learn from our experiences and do something. In the absence of randomized, controlled trials, sometimes these small “pearls” of experience can save lives. Our patients expect no less.
The risk management literature shows that patients with an unexpected outcome and their families ask three questions that require full, honest disclosure: “What happened?” “How did it happen?” and “What are you going to do so that it never happens again?”
It was with this principle in mind that the AAOS recently ran its first contest for Patient Safety Tips. There were more than 50 responses. AAOS immediate-past president James H. Herndon, MD, recognized John M. Purvis, MD, at the 2004 Annual Meeting for his Grand-Prize-winning tip: “P.R.E.P.A.R.E. for surgery. This simple acronym serves as a checklist in the operating room: Procedure plan, radiology, equipment, patient verification, anesthesia, Rx given and exceptions.” This and other valuable tips judged the “Top Ten” by the AAOS Patient Safety Committee were published in the April 2004 Bulletin. I would like to expand on the basic listing of the tips and provide more in-depth information about them in a series of articles in future issues of the Bulletin.
The first of the “Top Ten Tips” is an excellent example of experience turned into a safety practice. Tip #1 was “Never place a toxic dose of solutions for injection in the OR. This way, even if the entire amount is injected, no adverse effects will occur.”
To learn more about this suggestion I recently spoke with the orthopaedic surgeon who submitted this advice, Glenn R. Rechtine II, MD, of Gainesville, Fla.
“When I was in training,” explained Dr. Rechtine, “a senior resident performing spinal surgery demanded a syringe of epinephrine solution from the scrub nurse. When she tried to point out the dose, he impatiently cut her off. Luckily, members of the surgical team spoke up before he injected the entire contents of the syringe—a potentially toxic dose. Now, I teach my residents to have only a limited amount of drug on the field at any time, so that a toxic amount cannot be accidentally given. Also, whenever I receive a syringe for injection, I always ask three questions: What is it? Who mixed it? and How was it mixed?”
What Dr. Rechtine has done is to think ahead. He has anticipated what could happen to some future patient and he’s changed the process of his care so that his patients are protected.
Every day, Academy members like Dr. Rechtine are thinking about changing systems. We place fail-safe blocks in common procedures to prevent harm. We communicate these ideas and practices to our peers and students. We turn potential problems into pearls of wisdom. By doing so, we again turn the wrench to reduce medical errors and improve the safety of our patients.
Robert L. Brooks, MD, PhD, is a member of the AAOS Patient Safety Committee.