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EDITORIAL |
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Cardiothoracic Surgical Unit Royal Prince Alfred Hospital Sydney, Australia |
It was an Australian chemist, David Warren, who turned around industry thinking. He did this quite simply. He devised a way to record what was happening as it happened — the "Black Box" (which is neither black nor just a box!). The flight data recorder and the cockpit voice recorder have become the most useful pieces of evidence in almost every incident. They have made a dramatic improvement to our safety in the air. Now we can fly assured that the risk of a major accident is 2 per million departures, despite the exponential increase in traffic.
There are great similarities between the airline industry and surgery. Both use the most advanced technology, both have the lives of thousands in their control, and failure is associated with death or serious morbidity. Between 44,000 and 98,000 patients die each year of preventable errors in American hospitals, more than the total deaths attributable to motor vehicle accidents or breast cancer.1 There is still much for surgeons to learn when we consider the way we handle "adverse outcomes." Our sense of personal responsibility often prevents us as individuals from addressing correctable factors in either the system or our own actions. Such myopia only puts more lives at risk unnecessarily. Peer review and quality assurance programs are the "Black Box" of surgery. And yet so few of us utilize anything remotely resembling the discipline of our colleagues in the cockpit, such is our fear of another profession, the law. Perhaps that is why we seem so far behind the pilots in risk prevention. Were we to implement standard simple audits, regular peer review, credentialing, and precise retraining procedures, we too could reduce the risk to our patients by a factor of 20.
Leaving aside the preeminent need to "above all, do no harm," why else should we implement quality assurance programs? First, if we do not, someone else will! We do not have the monopoly on safety. Our patients will seek out assistance from those who can help. The first call is often (and not surprisingly) to the law. And help it can. The legal system has huge resources to investigate, prosecute, and punish:– but all after the event, often by many years. Meanwhile, countless others may be un-necessarily harmed or even doomed. Prompt quality assurance programs should prevent the next mishap. If not the law, then perhaps the press will become involved in the crusade. Its resources are more often applied to the story itself and/or blame than to correcting the problem. Sensational reporting might highlight the issue but rarely provides a solution and often apportions blame incorrectly. Detailed quality assurance will focus on the real problem with a view to harm minimization and reeducation.
Second, investigation by those not skilled in the intricacies of a specialty may miss key factors in the incident. Failure to wean from cardiopulmonary bypass may be due to poor myocardial protection (inappropriate dose, delivery, or type of cardioplegic solution) or it may be due to failed revascularization (kinked graft, radial artery spasm, wrongly placed anastomosis) or it may be the result of delay in referral or preoperative myocardial infarction, aside from technical events such as dissection etc. Those at the coalface are in the best position to note the real circumstances of the incident. Third, remote investigation may overlook small but critical "peripheral details." The frail elderly patient having combined coronary and valvular surgery may not have died because "she was too frail" but because her urinary tract infection was not detected or treated until she developed catheter-induced septicemia. Fourth, what better education than real case studies! It has been said, "any fool can learn from their own mistakes but the wise learn from the mistakes of others." More importantly, the truly great will tell all of his or her errors so that they are not repeated! Fifth, good economic management demands it. The costs of diagnosis, management, and rehabilitation are clearly an enormous drain on the public purse. Finally, we should not fear the truth! It is unassailable. It will come out and it is a matter of public record (if the patient notes are of any use at all).
What then is the best mechanism for quality assurance? Simply put, one that delivers! Huge centrally coordinated databases may have some use for health economists but in isolation, rarely help individuals. A regular unit-based contemporaneous review of activity is difficult to better when seeking to improve outcomes. All surgeons should have a comprehensive surgical audit. All adverse events should be recorded, all mortality and sentinel events discussed, and key performance indicators reviewed regularly. Aggregated, de-identified, and risk-stratified data can then be passed on to the larger central database for healthcare planning. However, long before the statistics are collated, the problem should have been remedied. After all, excellence is our core business! If the plane crashes, so does the pilot. If we lose our patients, we lose our friends and our business.
If there really is a "Tree of Knowledge" then quality assurance buds when we measure what we do. It develops as we compare what we achieve with others. It ripens when we recognize failings and implement changes, it matures when we are bold enough to educate others and it bears fruit when the lessons are learnt and applied more widely to our individual practice. It was not the "Black Box" that, of itself improved safety, but the remedies to lessons learnt from an objective contemporaneous record. But those lessons could only be applied if public discussion followed. The dissemination of the lessons from ex-perience needs to be widened. Whilst authors rightly seek a few highly reputable journals, the invaluable contribution of regional publications is often overlooked. With a few notable exceptions, the mainstream publications tend to focus on advances in medicine as defined by science or bigger and better series.2,3 Only a few courageous authors and editors have been brave enough to even raise the issues of avoidable or human error.4,5 We can and must share our local experiences, good and bad, collate and expand the data and learn before it is too late. Regional well-written and reviewed journals with a strong clinical emphasis should encourage and report on surgical audits. De-identified, risk-stratified multicenter data in the clinical domain is an essential tool for quality assurance. Then the lessons learnt by effective comparative peer review processes might warn of, or even prevent, a repetition of what has become known simply but condemningly, as "The Bristol Affair."
References
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