Can Wrong-Site and Wrong-Patient Procedures Be Totally Eliminated?

Last week, MedPageToday asked its readers to answer the question “Can wrong-site and wrong-patient procedures be totally eliminated?” About 70% of the 727 respondents said “Yes.” I say, “No.” Here is why.

The paper from Archives of Surgery, “Wrong-site and wrong-patient procedures in the Universal Protocol Era,” which generated a lot of media interest, contains the answer. The paper is a retrospective study of a medical liability insurance company’s self-reported database of adverse occurrences. There were 25 wrong-patient and 107 wrong-site procedures reported over a 6.5 year period [2002 to mid-2008]. The Joint Commission mandated the Universal Protocol as of July 1, 2004. It called for a pre-procedure verification of the patient, procedure and site, marking of the procedure site and a “time-out” or review of the planned procedure involving all care-givers. According to Figure 3 of the Archives paper, the number of wrong-patient and wrong-site procedures was remarkably consistent over the years of the study which included years before and after the institution of the Universal Protocol. Providers either ignored the protocol or failed to execute it properly.

The factor that will prevent the total elimination of wrong-patient and wrong-site procedures is us. As long as humans are in the equation, human errors will persist.

A recent paper from the British Journal of Surgery entitled “Nature, causes and consequences of unintended events in surgical units,” described 881 self-reported unintended events in 10 hospitals in the Netherlands over a one year period. Human error was the root cause in over 70% of instances, with system errors comprising only 16%. Similarly, an article from San Diego by the leaders of one of the most mature trauma systems in the country, noted a stable rate of complication ocver a 12-year period. While human errors decreased over time, they could not be entirely eliminated. Lack of adherence to guidelines, fatigue, inexperience and other human issues were cited as continuing problems.

Finally, no less an authority than Donald M. Berwick himself has stated “The search for zero error rates is doomed from the start.” [Quoted in Graber M, Gordon R, Franklin N. Reducing diagnostic errors in medicine: what's the goal? Acad Med. 2002;77:981-92.]

Medicolegal Musings: Physician Posting on Social Media & the Internet

You are in the middle of a deposition. Plaintiff’s lawyer asks, “Do you blog or tweet?” Before you answer, consider this. If you blog or tweet and respond in the affirmative, I believe anything you have ever posted would be subject to discovery by the plaintiff. Oh, you post anonymously? Would you then lie under oath and say you do not blog or tweet? For many physicians, admitting that you blog or tweet might not be a problem. But in my short career as a blogger/tweeter, I have read some things that frankly would not enhance a malpractice defense if projected on a large screen in front of a jury.

I will allow that I am skeptical and sarcastic, but I do not think I have posted anything that is derogatory to a patient, either generally or specifically. There are some very popular anonymous doctor-tweeters who post some scathingly negative comments about patients. Even if a patient could not be identified, the tone of some of these posts implies a deep-seated resentment of patients and their problems, not to mention many are vulgar, sophomoric or both. OK, some of them are funny as well, but the humor would be lost in a courtroom. Some of these tweeters disseminate prodigious numbers of posts per day perhaps suggesting that they are not always focused on their work.

I have followed several medical bloggers who post clinical anecdotes, which are essentially case reports. Despite disclaimers stating they are not about real patients, it seems obvious that they are. If the subject of one of these case report blogs decides to sue, it might be difficult to convince a jury that the blog was about a fictitious case. And this type of publication might be considered a HIPAA violation especially because it is unlikely that a blogger would have obtained institutional review board permission to publish the case report.

By the way, if you blog or tweet anonymously and answer falsely that you don’t, you better never have told anyone that you do. A lie under oath that is discovered tends to undermine your credibility quite a bit. [Defense lawyer, “Your honor, may we have a short recess while I talk to my client.”]

As far as I know from an attempt to search for medicolegal references to Twitter and blogging, this perspective has not been brought up before. What do you think?

“Body Size Misperception” May Be a Factor Contributing to the Obesity Epidemic

Did you ever wonder, as I often have, what obese people are thinking as they keep putting on weight? Why doesn’t it occur to them as they pass, say 250 lbs., that maybe they should stop eating so much? As published two weeks ago in Archives of Internal Medicine*, researchers in Dallas suggest that a substantial number of obese people have what they term “Body Size Misperception.” More than 2000 obese adults were shown drawings of human figures on a 9 point scale, ranging from very thin to very obese. They then were told to pick both a figure that they felt would be ideal and a figure that represented how they thought they appeared. Body size misperception existed if the subject chose an ideal body size that was the same or larger than his/her actual size.

Some 8% of the group exhibited body size misperception. In other words, these people did not recognize that they were obese. Further examples of denial were that the body size misperception cohort felt they had a low lifetime risk of heart attack, high blood pressure and diabetes. The most amazing revelation is that a full two-thirds of these already obese individuals considered themselves at low risk for developing obesity. The authors of the paper think this issue is under-publicized and generally not dealt with well by physicians.

Maybe the concept of body size misperception, an entity that I certainly was not aware of before, can explain the apparent lack of self-recognition that one might be obese. And lacking the ability to see this obviously explains not only why some people become morbidly obese but also why they don’t seem inclined to correct the situation.

*Powell TM, et al. Body size misperception: a novel determinant in the obesity epidemic. Arch Intern Med. 2010 Oct 11;170:1695-7. [No abstract available]

Hospital Ratings Revisited

A recent press release from HealthGrades claims that some 232,442 Medicare patients’ lives could have been saved over a three-year period if all hospitals performed at the level of a HealthGrades five-star hospital. While this is a laudable premise, can it be true? Let’s see.

First you need to know something about HealthGrades and its rating system. Using a large Medicare administrative database (that is, the data are submitted by hospitals for billing purposes), HealthGrades compares hospitals on an observed vs. expected outcomes basis. For some reason, hospitals are rated as five-star (best), three-star (as expected or average) or one star (poor). There is no mention of four- or two-star. And according to their methodology, “…70% to 80% of hospitals in each procedure/diagnosis were classified as three stars, with actual results not significantly different from predicted results. Approximately 10% to 15% were 1-starhospitals and 10% to 15% were 5-star hospitals.” For non-statisticians, that would be classified as a normal distribution.

Now what would happen if every hospital in the U. S. performed at the level of a five-star hospital? Well, the observed rate of complications and deaths would go down but as long as one compares observed vs. expected outcomes, the distribution of hospital ratings would still be normal with 10%-15% being above average, 70%-80% average and 10%-15% below average.

Therefore, with the possible exception of hospitals in Lake Wobegon (“Welcome to Lake Wobegon, where all the women are strong, all the men are good-looking, and all the children are above average.” [Garrison Keillor]), all hospitals cannot be above average.

Then there is the problem of using administrative databases to judge clinical outcomes. By this passage from HealthGrades’ own description of its methodology the following disclaimers are listed.

“Limitations of the Data Models
It must be understood that while these models may be valuable in identifying hospitals that perform better than others, one should not use this information alone to determine the quality of care provided at each hospital. The models are limited by the following factors:

“Cases may have been coded incorrectly or incompletely by the hospital.
The models can only account for risk factors that are coded into the billing data–if a particular risk factor was not coded into the billing data, such as a patient’s socioeconomic status and health behavior, then it was not accounted for with these models.
Although Health Grades, Inc. has taken steps to carefully compile these data using its methodology, no techniques are infallible, and therefore some information may be missing, outdated or incorrect.”

There are a number of peer-reviewed articles questioning the validity of using administrative databases in clinical outcomes research. A study of patients with cerebral aneurysms, from the Bloomberg School of Public Health at Johns Hopkins University, found many large discrepancies between the Maryland state administrative database and the clinical records of the patients at their institution. A paper from Harvard and Tufts concluded “Cardiac surgery report cards using administrative data are problematic compared with those derived from audited and validated clinical data, primarily because of case misclassification and non-standardized end points.” A systematic review of papers on infectious diseases found that administrative databases have “limited validity” for the evaluation of co-morbidities, a key factor in risk adjustment.

Try this for some hospitals that you might be familiar with. Compare HealthGrades ratings with “Medicare Hospital Compare,” which one must assume is using the same outcome data since HealthGrades uses Medicare’s data for its ratings. Here are the results for heart attack outcomes for three hospitals in New York City. (See Table.) The rating scales are the same, three possible grades.


I don’t know which one to believe. Do you?

Note: A previous blog post of mine pointed out a few other issues with HealthGrades that everyone should be aware of.

Why Reporters (And Hospital Administrators) Should Learn Statistics

Interesting article on amednews.com about the pros and cons of publically posting emergency department waiting times. The pros are that patients can self-triage to the least busy ED, and it might be good for a hospital’s business. The cons are that patients who are really sick might be discouraged from going to any ED if the waiting times are long, and ED doctors might cut corners to speed patient throughput.

One paragraph of the article caught my eye.

“Scottsdale Healthcare began posting wait times in April 2008 at its four EDs, all of which are within about 15 minutes' driving time of one another in the city (two -- a general ED and a pediatrics ED -- are housed at the same center). Its patient satisfaction scores have improved by 2 percentage points [emphasis added], said Nancy Hicks-Arsenault, RN, the organization's systems director of emergency services.”

I can’t be sure but knowing what I do about patient satisfaction scores [a good subject for future blog], I would bet that a 2% increase in patient satisfaction is not statistically significant. In my experience, fluctuations in patient satisfaction scores of 2% are common and well within one standard deviation of the average for these rather crude measures. One of the most popular patient satisfaction survey companies uses a rating scale of 1 through 5 and then converts the responses into percentages. This means that if a patient rates an ED service as a “4” instead of a “3”, that is a 20% increase in satisfaction when the patient may not really have been 20% happier with his experience. The response rate of most patient satisfaction surveys is usually below 10% which further diminishes their validity.

I would have asked to see the raw numbers, performed a statistical test and determined if a 2% increase in patient satisfaction was real or not.

Reporting Wrong-Site “Surgery”: Errors and Omissions

This morning, four health-reporting websites [New York Times, MedPage Today, CNN Health, Science Daily] reviewed a paper that appears in the October issue of the journal Archives of Surgery entitled “Wrong-Site and Wrong-Patient Procedures in the Universal Protocol Era.” The paper documents a number of wrong-site and wrong-procedure incidents from a medical liability insurer’s database in Colorado. The incidents were self-reported by physicians without penalty. It is an interesting study that bears reading but the full on-line version is only available by subscription. So at this time, we only have the abstract of the paper and the reports from the four news organizations to go by.

What strikes me is the manner in which the story is reported. Although the study clearly states that these adverse events were caused by surgeons and non-surgical specialists in equal numbers, three of the four websites headlined the story as follows:

“Wrong Surgery on Wrong Patient Still Happening”
“Surgical Errors Continue Despite Protocols”
“Surgery Mix-Ups Surprisingly Common”

Only one site, Science Daily, used a headline consistent with the title and content of the paper, “Study Documents Wrong-Site, Wrong-Patient Procedure Errors.” That outlet also went into some detail about the percentages of specialists report errors, mentioning that internists were responsible for 24% of the wrong-patient procedures.

A casual reader of one of these articles might assume that these incidents are happening every day. The paper recorded only the submitted events, not the denominator, which would be the number of opportunities to experience an adverse event. The use of a self-reported database is not the same as an epidemiologic study, but only two of the four reports [MedPage Today and NY Times] took the trouble to point this out. The NY Times cited a previous estimate that adverse events such as those documented in the paper occur about once in every 110,000 procedures. This is a serious topic and one which deserves the coverage it is receiving but more accurate reporting and more thoughtful analysis would inform the public better.

There are some other questions about the paper such as how many of these adverse events pre-dated the institution of the universal protocol, which calls for a “time out” and other measures to prevent such incidents. The paper covered the years 2002-2008 and the Universal Protocol was mandated by the Joint Commission in 2004.

I will review the paper in depth for you when I get the full version.

Proof That Our Country’s Education System Is in Serious Trouble

Here is an actual problem from a fourth grader’s math workbook. [See photo.] Since the photo is a little dark, I have transcribed it below.

“Reasoning Hwong can fit 12 packets of coffee in a small box and 50 packets of coffee in a large box. Hwong has 10 small boxes and would like to reorganize them into large boxes. Which boxes should he use? Explain.”

Speculation has ranged from the Stonehenge and pyramids lining up with Orion to Fermat’s last theorem to just chalking it up as an inscrutable mystery of the Orient.

If you can deduce the answer, please explain it to me so I can explain it to a 10 year old.