The Doctor Weighs In

By Dov Michaeli MD, Ph.D.

I often wondered why it is that the practice of medicine is so error-prone. Hundreds (yes, hundreds) of patients die every year because of errors in administration of medications. Or, how about the cases from hell of the wrong leg amputated, the wrong breast removed, the wrong eye enucleated? Is it even imaginable that a car would be produced that has wheels of different sizes? The cliché that “if we can send a man to the moon, why can’t we … (fill in the blanks)” is actually thought-provoking. Sending a man to the moon entails a vast amount of detail, inordinately complex coordination of interacting systems and sub-systems, and concerns of safety at every step of the way. Yet, several well-known mishaps notwithstanding, NASA’s track record is admirable. Or consider the airline industry; if it had proportionately the same rate of errors as medicine, only intrepid adventurers would dare to fly.

Borrowing from the best

The summer issue of Proto, a magazine published by the Massachusetts General Hospital (www.protomag.com) looks at how the most progressive medical centers and medical groups are turning to industry, the military, airline pilots—anybody or anything that can teach how to run a seamless, error-free operation. Here are a few examples cited in the article.

· New York-Presbyterian Hospital trained more than 200 doctors, nurses and administrators in Motorola’s Six Sigma management system. These “black belts” are constantly on the prowl, looking for ways to improve the way the hospital runs. Estimated savings: $65 million. A friend of mine was recently hospitalized there with an exceedingly complicated condition. I couldn’t help marveling at the competent, efficient and friendly manner with which he was treated, despite the multiple disciplines that were involved in his care.

· Virginia Mason Medical Center in Seattle sent physicians and administrators to Japan to study the fabled Toyota Production System, which was developed after WWII to eliminate mistakes, reduce waste and empower frontline staff to institute improvements. On the assembly line, they learned how to deconstruct a job into specific tasks, reconstruct it so as to maximize efficiency, and then redesign the process so that each step could be reproduced by anybody doing the job. Assembly line medicine, you might aver. There is a lot to be said for assembly lines. I experience the joy of assembly line efficiency every year when I receive my flu shot at Kaiser. You are moved from station to station, each one performing a single task (hand out consent forms and instructions, collect signed forms, administer injection). Hundreds of people a day go through the process—and you are out the door in less than 5 minutes.

· Doug Bonacum joined Kaiser Permanente as VP of safety management, after eight years in the Navy submarine force. At a conference on perinatal safety he was struck by the complaints of nurses that when they thought a labor was not progressing as it should, their concerns were ignored by physicians. Doctors, on the other hand, complained that nurses did not express themselves clearly and quickly. In a submarine clear and concise communication is essential in situations that require quick responses, and the margin for error is quite small. Together with two colleagues, Bonacum developed a communication protocol based on the one used in the Navy. The SBAR system—situation, background, assessment and recommendation—is now used at Kaiser in everything from shift changes for nurses at the hospital, to managing critical events in the ER. The process begins with a summary of the current situation, followed by a succinct background on the patient, a clear assessment of what the staffer thinks is going on, an a recommendation of what should be done.

· The University of California , San Diego Medical Center , is instituting in the OR the seemingly excessive ritual a pilot and co-pilot go through before take-off. The pilot says “flaps” and checks the flaps. The co-pilot checks the flaps and answers “flaps”. Then the pilot rechecks the flaps. And so down the whole checklist. Using this procedure, it would be almost impossible to leave an unaccounted sponge in a patient’s abdomen; too many people have to keep count, and confirm the others’ count. And during an operation anyone has the power, and the responsibility, to halt the procedure if something doesn’t look right.

Physicians hate regimentation. I remember my frustration when in training I was forced to follow protocols of taking history, physical exam, differential diagnosis and detailed report writing, when it was ‘obvious’ that the patient had, say, a simple rash. But it kept me (and the patient) out of trouble.

One of those ‘simple’ rashes turned out to be an unusual presentation of malignancy. I gained an enormous respect for protocols, as well as some sorely needed humility.

Dov Michaeli MD, PhD. Is currently in the Biotech industry, involved in drug development.