Health care is risky business. And while checklists, as advocated by Dr. Atul Gawande in his book The Checklist Manifesto, are a good start in reducing medical errors, they aren’t enough. The overall mortality rate in pediatric cardiac surgery nationally remains around 3 to 4 percent – even after implementing checklists.
We need to do something to get from a rate of three or four in 100 to one in a thousand, or one in ten thousand, as we see in other industries, such as airlines. At Cincinnati Children’s Hospital Medical Center, that something is an effort to create the safest operating room.
The traditional way of thinking about medical errors is to examine events that are directly linked to patient safety. (It doesn’t help, either, when we surgeons believe that we are above mistakes.) But there is no way to predict in advance which of the many small and often unnoticed incidents that occur in an OR will remain isolated events and which might materialize into problems.
That’s why we began accounting for unexpected events that never would have been recognized or captured before. We noticed that these events fell into nine categories of recurrent patterns. We then began implementing system changes and process improvement measures to reduce events in particular categories. Unless we eliminate all of them, no matter how minor they might appear, we’ll never get to a 100 percent assurance of safety.
We are about to enter a new generation of safety at Cincinnati Children’s. We envision an OR with a glass ceiling – literally. Above it is a control room where a stage manager or air traffic controller monitors the many intraoperative activities of the diverse individuals who work below. Parents would be invited to watch their own child’s surgery, if they wish. At the end of the procedure, families would receive a DVD of the operation.
When people decide they need surgery, the first question they ask is, ‘Who is my surgeon?’ But when they get on a plane they don’t ask, ‘Who is my pilot?’ We need to develop systems that are just as reliable and safe. We owe it to our children.
Pirooz Eghtesady, MD, PhD, served as the interim director of cardiothoracic surgery in the Heart Institute at Cincinnati Children’s.
