Helmut* was one of my cancer patients. He also had a painful, nonvisual eye. The eye ended up giving him more trouble than the tumor and the owner elected to have it removed. She had it removed by a board-certified ophthalmologist (not at the hospital I work at, I hasten to add). There was a horrible mistake made. The normal, visual eye was removed and it wasn’t until after it was over that the veterinarian realized the mistake.
The client received a phone call during surgery to ask her what she wanted to do. She said to go ahead and remove the painful eye, because it was nonvisual anyway and it was affecting his quality of life. She then tried her best to rehabilitate her newly blind dog, but he didn’t adjust. He was almost deaf as well, and the acute and complete loss of his vision was too much for him. She euthanized him several weeks later, right after Christmas last year. This was and is a nightmare for all involved, especially for Helmut.
How could this happen? And, I am sure you are thinking. Who did this? Well, to answer the second question, it doesn’t matter and to answer the first, anyone could have made this mistake. It was human error. There is a culture of shame and blame in veterinary and human surgery that prevents us from talking about medical errors. It is so much easier to assign the blame to an individual, rather than a system or institution. Wrong site and wrong side surgeries happen in both veterinary and human surgery.
[tweetthis]A culture of shame and blame in veterinary surgery prevents us from talking about medical errors. [/tweetthis]
Could this have been prevented? Absolutely. Dr. Atul Gawande has worked with a team and the World Health Organization to develop an exquisitely simple system to prevent errors like this in human surgery, a surgical checklist.
Checklists are used extensively in the airline industry to guard against human error. They are new to human and veterinary medicine, which shocks most people in the airline industry. The checklist is there to ensure that the routine things that are easy to forget or miss are systematically communicated and verified. Confirming the patient’s identity and surgical site/side, ensuring that antibiotics were given in a timely fashion, ensuring that the team has discussed potential complications or steps that are not routine preoperatively, and counting instruments and sponges.
Dr. Gawande tested the surgical safety checklist and found a significant reduction in morbidity and mortality at six different hospitals in the developed and developing world. He wrote about the surgical checklist in his book, The Checklist Manifesto. (I highly recommend this book!) I started using a checklist as soon as I finished reading Atul Gawande’s book in 2010. Now I can’t imagine doing surgery without one.
The effect of the checklist is several-fold. It focuses and empowers the team, it allows for a double-check system, it is an efficient way to go over the critical information about a case in an organized fashion, it ensures that sponges and instruments are counted in and out, and it changes the work culture for the better. The medical term “retained” surgical instrument is an indication of the bizarre blaming culture in medicine. In this case, the abdomen is blamed for actively hiding the instrument inside, rather than the surgeon forgetting it in there.
Since the surgical safety checklist came out, there has been a flurry of papers in human medicine confirming its efficacy in reducing complications in different areas of surgery. What followed is another flurry of papers on implementing the checklist and how to deal with institutional or personnel resistance to the checklist. Surgeons often resist because they are offended by the suggestion that they might make a mistake and they complain that pausing for the checklist will slow them down. The checklist is actually a faster and more efficient way to convey information once it is implemented.
I would argue that you don’t have time not to use the checklist. Further, the checklist is not there to protect incompetent people. Incompetent people will be incompetent with or without a checklist. It is there for people that are people. We all get tired, make mistakes, get distracted, rush when we shouldn’t rush, or forget to let team members know something that may improve the outcome in a case.
Most communication failures in medicine are due to either occasion or audience. Occasion, meaning that the timing of the information was suboptimal, and audience, meaning that the information was not conveyed to relevant team members. The checklist helps with this because it brings the team together at timely breaks to ensure that everyone is on the same page at the right time. The other less common communication failures include: content, meaning that the information is wrong, (checklist may not help here) and purpose, meaning that you work with a dick. (Checklist can not help you with this either.)
So, if you are not already, consider bringing a checklist system into your surgical practice. It will bring order to the chaos on your busy days. It will make your technicians happy because it will help them to do their jobs better. It will help to keep your procedures moving. It will improve the communication of your whole team. Most importantly, it may help prevent you from ever making the mistake that Helmut’s veterinarian made.
[tweetthis]You don’t have time not to use the checklist.[/tweetthis]
These veterinary horror stories rip through our profession and become legends of veterinary lore. Usually, they are accompanied with an unhealthy dose of shame and blame and they lack a concrete method to prevent these errors. That is ulcer-inducing and wholly unhelpful. Medical errors and adverse events are a part of veterinary and human medicine. Surgical checklists can help us to pick up on the preventable ones so that a wrong side surgery becomes a near miss in your practice and not a devastating surgical complication.
*Name of pet has been changed