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Things doctors should not do—like attacking their nurses

Things doctors should not do—like attacking their nurses

Do not [allegedly] assault the nurses. A former nurse at a surgery center affiliated with Cedars-Sinai Medical Center in Los Angeles is suing an ophthalmologist who, she alleges, pushed her out of an operating room. Surveillance video shows what happened. An article in Modern Healthcare says the doctor then grabbed the nurse’s arm and told her he could do it because he knew she liked abuse. The nurse’s lawyer said his client was punished with a transfer and a decrease in her work hours leading to her eventual resignation. Cedars-Sinai declined to say whether the doctor had been disciplined. A surgeon at a Long Island, New York hospital, angry because a nurse gave one of his patients a dose of medicine at the wrong time, allegedly took a drawstring from his sweatshirt and wrapped it around her neck. As reported by Outpatient Surgery, the complaint says the surgeon, while choking her, told her he should kill her for what she did. He was arrested and charged with strangulation and assault. Whether he was sanctioned for wearing a hoodie in the OR is unknown. Do not carve your initials in the organs of patients you are operating on. Simon Bramhall, a surgeon in Birmingham, England was £10,000 for using an argon beam coagulator to carve his initials on the organs of two different patients while they were undergoing surgery. He pleaded guilty to one of the two charges and said he did it to relieve stress in the operating room [not an accepted method of relieving stress]. The offenses were discovered when the patients were re-operated on by other surgeons....
Things medical personnel should not do

Things medical personnel should not do

Here are some tips from an experienced former provider—me. Nude Pictures… Do not take nude pictures of fellow employees. A woman unit secretary in the operating room of a hospital in Greene County, Pennsylvania said while she was anesthetized for an incisional hernia repair, an operating room nurse took photographs of her naked body and later showed them to several coworkers. The patient, known only as Jane Doe, has filed suit against the hospital, several of its employees, and the surgeon who operated on her because he did not report the nurse who took the pictures to hospital administration. According to the local newspaper, the OR nurse was fired after Ms. Doe reported the incident, but things did not go well for Ms. Doe either. After she returned to work, she was blamed for what happened and treated poorly by the staff. Someone wrote her a note that said, “What were you thinking?” and added an obscenity. She returned to work and suffered “migraines, anxiety, and insomnia.” After she took an unpaid leave recommended by her physician, the hospital terminated her. As is typical of lawsuits such as this [see my post of December 28, 2017], hyperbole must be used in order to fill up the 39 pages of the complaint. Despite no claim of a postoperative complication, Ms. Doe’s lawyer said she was at increased risk of infection because a cell phone, not necessarily one with more bacteria than a toilet seat, was taken into a sterile operating room. Murder… Do not [allegedly] murder a patient. An anesthesiologist was arrested and charged with murder in December because his...
Going off the deep end about water

Going off the deep end about water

The latest water craze has generated a lot of discussion. The New York Times reported that some people in California [where else?] have started drinking “raw water” which is “unfiltered, undertreated, unsterilized spring water.” Why are they doing this? They claim that tap water should be avoided because of fluoride. Google “evils of fluoride,” and you’ll find treatises such as “Top 10 dangers of fluoride.” What, only 10? Bottled water is not the answer because it is also treated to remove some minerals and beneficial bacteria. Before you go out and buy some raw water—also known by the brand name “Live Water” [eliminating the pejorative word “raw”], be aware that since the Times piece, a gallon costs $60.99. and as of this writing, it is back ordered. And here is a list of organisms that can be found in untreated water—giardia, legionella, norovirus, campylobacter, cryptosporidium, salmonella, and E. coli. Some illnesses resulting from drinking contaminated water can be fatal. Maybe the name “Live Water” is meant to alert you to the fact that it contains living things. The founder of the company that sells Live Water says drinking tap water is like “drinking toilet water with birth-control drugs in them [sic].” But he also points out that Live Water should be used “within one lunar cycle of delivery” because waiting longer may result in the water turning green. Sounds enticing, doesn’t it? Medical Twitter was not enthusiastic. Many commented that treated tap water has prevented diseases for the last 100 years or so. However, no epidemics will occur because an investigation by menshealth.com found Live Water comes from a...
Ordering unnecessary laboratory tests continues to be a problem

Ordering unnecessary laboratory tests continues to be a problem

Unnecessary testing wastes money and can lead to further testing. Why does it occur? Almost 60% of medical personnel surveyed at a large academic medical center believed that hospitalized patients should have daily laboratory testing. Of 1580 attending physicians, fellows, residents, physician assistants, nurse practitioners, and nurses sent surveys, 837 (53%) responded; 393 (47%) were RNs, and 80% of those nurses felt that daily laboratory testing should be done on all patients. Nurses strongly felt that patient safety and protection against malpractice litigation were enhanced by daily laboratory testing. Of note is that more than half of those who returned completed surveys said they thought attendings would be uncomfortable with less testing, and 37% said they ordered unnecessary tests to satisfy attendings. However, the category of respondents who least felt daily tests were needed was attending physicians at 28%, and 84% of attending physicians said they would be comfortable if their patients had fewer laboratory tests. Unnecessary lab testing on their units was observed by 60% of respondents, but only 37% said they had requested unnecessary testing themselves. Perhaps the unnecessary tests had been ordered by people who did not respond to the survey or the tests were ordering themselves. The authors of the JAMA Internal Medicine study, done at Memorial Sloan Kettering Cancer Center in New York, concluded that although nurses did not order laboratory testing themselves, they might have some effect on the frequency of lab tests being done. Another recent survey published in Hospital Medicine asked internal medicine and general surgery residents at the Hospital of the University of Pennsylvania why they ordered unnecessary tests as...
Surgeon sued for talking on cell phone during an operation

Surgeon sued for talking on cell phone during an operation

A surgeon took a Spanish language proficiency test while performing varicose vein surgery on a 70-year-old woman. The doctor said he had to take the test during the procedure because no other time was available. Since the case was being done under local anesthesia, she could hear what he was saying. She said she speaks Spanish, heard him talking about diabetes and blurred vision, and was fearful for her safety because she thought the doctor was talking about his own medical problems. Nothing is more distracting than a cell phone in the operating room. In a perfect world, we would leave our cell phones in our lockers and sign out to another surgeon to cover us while we are operating. Unfortunately, the world is not perfect. Many times when I was on call, I was the only general surgeon covering two hospitals. I had to have my cell phone in the operating room to field any calls that came in. However, I cannot condone the actions of the surgeon in this case. Taking a language proficiency test while operating is inappropriate. According to a report, he admitted this as did his group’s medical director and risk management administrator. A malpractice suit has been filed alleging the patient suffered emotional distress which is still ongoing. The outcome of the procedure is not an issue. I have several thoughts. If the test was offered at only one time, he should have scheduled the operation for another time. If the patient was fluent in Spanish, she must have realized the surgeon was not talking about his own medical problems. A successful malpractice...
Patient satisfaction surveys are worthless

Patient satisfaction surveys are worthless

For several years, Medicare has tied hospital reimbursement to its definition of quality of care. Poorly performing hospitals can be penalized as much as 2% of their Medicare payments. As part of Medicare’s assessment of quality, surveys are used to measure patient experience and satisfaction. One of the components of the Medicare survey is pain management, which Medicare describes as follows: I’m not sure who, if anyone, does Medicare’s copy editing, but that’s the way it looks in a screen grab from the website. The emphasis on “always” controlling pain, which many patients equate with “no pain,” is one reason we have an opioid epidemic. How valid is patient satisfaction as a measure of quality? Some conflicting research has been done, but a recent paper from JAMA Internal Medicine implies the answer is “probably not valid.” Researchers from the Department of Family and Community Medicine at the University of California, Davis surveyed 1141 patients immediately after they made 1319 visits to 56 different family doctors; 897 visits involved one or more patient requests with 1441 (85%) fulfilled. The authors did not comment on that percentage, but acquiescing to 85% of patient requests seems quite high. From 10% to 18% of patient requests for pain medication, referrals, laboratory tests, and new medications other than antibiotics or pain medication were refused and resulted in statistically significant decreases in patient satisfaction of 9 to 20 percentiles after the results were adjusted for numerous patient characteristics known to affect patient satisfaction such as age, sex, race/ethnicity, education, marital status, body mass index, overall self-rated health, mental health status, personality factors, life satisfaction, worry...
Elective surgery ban for smokers and obese patients

Elective surgery ban for smokers and obese patients

The committee that plans and oversees medical care for the county of Hertfordshire, England announced recently that unless obese patients lose a specified amount of weight and smokers quit smoking for at least 8 weeks, they will not be allowed to undergo elective surgery. Patients with a body mass index (BMI) greater than 40 must lose 15% of their weight within 9 months, and patients with a BMI over 30 must lose at least 10%. Free counseling for weight loss and smoking cessation is available to all. Variations of these rules have been in effect in about one-third of England for quite a while. In some areas, similar rules have been waived if patients fail to meet their targets after a certain period of time. The Hertfordshire rules are unprecedented because they are in place indefinitely. The idea is that losing weight might decrease hospital lengths of stay and the incidence of complications after surgery and lead to better outcomes while saving money for the National Health Service (NHS). Opponents question the ethics of the decision, doubt that withholding surgery will work, believe the delay will cause more suffering, and even may be more expensive because patients might need more care while they await their operations. According to a CNN story, the Hertfordshire committee countered that the policy would “encourage patients to take more responsibility for their own health and well-being.” More than 60% of adults in Hertfordshire, a county of over 1.1 million, are overweight or obese, and almost 16% are smokers. Surveys have shown that the public supports the committee’s proposal with 85% agreeing that people should...
Can a handheld ultrasound replace your doctor?

Can a handheld ultrasound replace your doctor?

    Dr. Mercola, described by Wikipedia as “an alternative medicine proponent, osteopathic physician, and web entrepreneur, who markets a variety of controversial dietary supplements and medical devices through his website,” is jumping the gun. Yes, it’s true that a handheld ultrasound connected to a smart phone enabled a man to diagnose his own cancer. However, it was not just any man. It was vascular surgeon John Martin, MD. As an advisor for the company that developed the ultrasound device, he happened to be testing it. Noticing a sense of fullness in his throat, he put the probe on his neck and found what turned out to be a 3 cm squamous cell carcinoma. He did not know it was a cancer at the time but was suspicious. As reported in the MIT Technology Review, he eventually had a biopsy, lengthy operation, and radiation therapy. The ultrasound device, developed by a company called Butterfly Network, is much smaller than a conventional ultrasound machine because it generates the sound waves using thousands of vibrating drums the width of a human hair instead of larger vibrating piezoelectric crystals. Because it is so advanced, the multiple probes used in previous generations of ultrasound machines are unnecessary. Here’s a photograph of the probe containing the entire works connected to an iPhone. The Butterfly ultrasound is much less costly than most conventional ultrasounds, which can run as high as the mid-five figures. The price will make it attractive to hospitals, doctors, and first responders, but $1999 would be a lot for an individual to pay for something not readily usable by the average patient....
A surgical resident’s legal battle with her program

A surgical resident’s legal battle with her program

  A surgical resident is suing St. Louis University, its surgical residency program director, and its trauma service chief for what she claims is an unjustified decision requiring her to repeat her fourth year of training. The St. Louis Post-Dispatch article about this has a link to a 42-page PDF describing the details of the suit. Because I suspect you won’t read that PDF and maybe not even the article, I will give you some highlights. Remember, these are allegations that have not been adjudicated. Because of poor scores on the American Board of Surgery In-Service Training Examination (ABSITE), she had been placed on academic probation at the end of her third year of training even though other residents with poor scores were not subjected to the same disciplinary action. At that time, she was not provided a faculty advisor as mandated by university policy. During her fourth year of residency, written evaluations by faculty were generally very good, but some oral feedback she received was negative. However, she received no specific recommendations for improving her performance. In fact, she contends that attendings on some services filed no written evaluations at all which is contrary to the regulations of the Accreditation Council for Graduate Medical Education—the national organization that oversees all residency training in the United States. She says some backdated written evaluations appeared in her file. The surgery department’s Clinical Competency Committee met and disregarded all of the written evaluations previously submitted for this resident. Instead they relied on hearsay and a “consensus letter” supposedly endorsed by all of the trauma service attending staff but later repudiated by...
Nearly 42% of users are satisfied with their EHR systems, survey finds

Nearly 42% of users are satisfied with their EHR systems, survey finds

Okay, what was your first reaction when you read the above headline? Mine was a tweet: “How’s this for positive spin? LOL.” Some responses to me. @cwrightmd tweeted, “I’m nearly 42% satisfied with mine.” @catjacarol01 said, “Less than half is supposed to be good? Try to imagine saying nearly 42% of patients survive this surgery.” @manders8589 wondered how many of the 42% were physicians who used the electronic health record clinically? Good question. The brief SmartBrief article linked to one on the website of Healthcare IT News which produced the survey. Details about it were sketchy. The number of respondents in various healthcare roles was not provided. All we know is, “The readers who contributed to our research run the gamut of hospital jobs: chief information officer, IT director, clinical engineer, application analyst, facility risk manager, telehealth coordinator, nursing informaticist and more.” Did that gamut included any nurses or doctors in the trenches? The article did not provide that information, nor did it say how the survey was conducted, how many people were surveyed, and how many responded. Healthcare IT News never missed an opportunity to portray the EHR in a positive light. Here is the Healthcare IT News headline. Another example is this glowing endorsement. When asked, “What was your overall satisfaction with the EHR system?” nearly 42 percent of respondents gave their system either an eight or nine on a scale of 1-10. More than 5 percent gave it the top “Most Satisfied” score.” Wow 5 percent! I am impressed. But my favorite part of the piece was this gem: Nearly half [well, almost 42%] of those...
Why public reporting of individual surgeon outcomes should not be done

Why public reporting of individual surgeon outcomes should not be done

  Last week Dr. Ashish K. Jha, a Harvard internist and health policy researcher, published an opinion piece in JAMA, advocating public reporting of individual surgeon outcomes [full text here]. I have followed Dr. Jha for many years on Twitter and have enjoyed his blog posts and papers. However, I must respectfully disagree with much of what he wrote this time. He tries but fails to refute the arguments that critics of individual surgeon reporting have put forward. For example, Jha says that the way to solve the problem of small sample sizes is to aggregate cases over several years. For most operations, aggregating over 3-4 years would still not yield enough volume for proper analysis. He feels that combining the outcomes for similar operations could make it easier to assess a given operation. To illustrate this point, he wrote “a surgeon’s performance on esophagectomy improves with the number of other similar surgeries she performs.” I can’t think of a single operation that is like an esophagectomy because the esophagus anatomically differs from any other organ. Jha says that publicly reported data would be enhanced by including confidence intervals “to highlight the level of imprecision so that those reading the report are aware of the statistical limitations.” I chuckled at that one because many physicians don’t understand confidence intervals. To expect the public to do so is wishful thinking. The notion that surgeons would avoid difficult cases so as not to tarnish their records is dismissed by Jha who says while citing no references, “the evidence on the extent to which this occurs is weak and anecdotal.” I will...
Do good online ratings mean you’re a good doctor?

Do good online ratings mean you’re a good doctor?

  If you are a patient looking for help when trying to find the right doctor, you probably think checking out online reviews would be a good thing to do. Two studies should give you pause. The first paper looked at risk-adjusted mortality rates for cardiac surgeons in 5 states (California, New York, New Jersey, Pennsylvania, and Massachusetts) that have published this data. Of the 614 surgeons whose information was public, 96% were rated on one or more of the well-known rating websites. The average risk-adjusted mortality rate for all the surgeons was 1.68% with a range of 0% to over 16%. The median rating for all surgeons was 4.4 on a scale of 1 to 5, and the median number of reviews per surgeon was 4. That’s right, 4. From the paper, the figure below shows the risk-adjusted mortality rate on the Y axis plotted against the average online ratings on the X axis. As you can see, ratings did not correlate with mortality rates, p = 0.13. Some surgeons with the highest risk-adjusted mortality rates had ratings of 5. The authors understated conclusion was “Patients using online rating websites to guide their choice of physician should recognize that these ratings may not reflect actual quality of care as defined by accepted metrics.” The second paper compared ratings data from three popular sites for 410 physicians who had been placed on probation by the Medical Board of California to controls matched by zip code and specialty. Again the average number of ratings was low at 5.2 for the probation group and 4 for the controls. Doctors with some...
Bladder catheter + oxygen supply tubing = death

Bladder catheter + oxygen supply tubing = death

  According to the coroner of South Australia, a 72-year-old former member of the Australian national men’s soccer team died a “horrific” and “macabre” death after his urinary bladder catheter was connected to his oxygen supply. His bladder then filled with oxygen until it burst. As the oxygen continued to flow at 2 L per minute, the resulting tension pneumoperitoneum caused his diaphragm to rise and eventually collapse his lungs so he could not breathe. The photo of an x-ray below illustrates what occurred. It is not an x-ray of the Australian patient, but the findings are similar to what would have been seen if an x-ray had been taken. The green arrows show the extent of the intra-abdominal free air leading to elevation of the diaphragm (blue arrows). The red arrows represent the decreasing lung volumes on both sides as the diaphragm rises. Not long after this tragedy came to light in late 2016, I blogged about the early progress of the coroner’s inquest. Speculation on how this could have occurred centered around two possibilities—the patient somehow cross-connected the tubing himself or a caregiver did so. As I explained in my original post, it was hard to imagine a confused old man figuring out how to connect two very different types of tubing. The coroner came to the same conclusion. A nurse said she had seen a white connector between the green oxygen tubing and the brown catheter but did not know what it was or understand its significance. Reports said the evidence was “destroyed” before it could be examined. Ironically, he should not have been receiving oxygen...
Money can’t buy drug adherence

Money can’t buy drug adherence

In June I asked, “Who’s to blame?” for patients not taking their medications and cited a couple of papers describing the poor state of medication adherence. I concluded nonadherence was a huge problem, and doctors failing to educate their patients was not a major cause. To support my contention that physicians are not the reason why patients do not take their medications as ordered I submit the following new information. A randomized clinical trial published online in JAMA Internal Medicine looked at patients who had been discharged after myocardial infarction and prescribed drugs known to decrease the incidence of future negative outcomes such as readmission for a vascular event including acute myocardial infarction, unstable angina, stroke, congestive heart failure, or death. The investigators looked at whether incentivizing patients to take their medications would have any impact on adherence. The study protocol called for two patients in the intervention group for every one patient in the control group. The 1003 patients in the intervention cohort received electronic pillboxes for their various cardiac medications, daily lottery tickets with a 20% chance of a $5 payout and a 1% chance of a $50 payout based on medication adherence for the day before, the ability to choose a friend or family member who would be notified if the subject did not use his electronic pill bottle [which could be programmed to contact the identified individual] for two of the three previous days, access to social work resources, and a staff engagement advisor to monitor and encourage adherence. The 506 control patients received no extra care nor did they have any further contact with...
How has United Airlines done since the doctor was manhandled?

How has United Airlines done since the doctor was manhandled?

  Three months ago I blogged about the doctor who was dragged off a United plane in Chicago and the airline’s response to the incident. The CEO claimed it was a system problem, but I thought human error and a lack of common sense were the major factors. I ended that April 17th post with three predictions: 1. The United fiasco will be forgotten by the end of this month. 2. People who said they will never fly United again will do so when they need to go somewhere serviced only by United or when United’s fare is the cheapest. 3. United will experience another “system error” very soon. Number 1 more or less occurred. I’m not sure about number 2. Regarding the third, here are some of the “system errors” United has experienced since then. A rare giant rabbit being shipped from London was found dead in the cargo area at Chicago’s O’Hare International Airport. No explanation of the cause of death was forthcoming. Probable human error. Two newlywed passengers recorded a video of jet fuel pouring out of the wing of a United plane about to take off from Newark to Venice. The husband “ran to let the crew know that something wasn’t right, but said they ‘yelled’ at him and told him to sit down, saying everything was normal.” When a crew member finally looked out the window, the flight was canceled. The couple was hassled when they asked United to book them on another flight. Eventually a Delta flight was arranged but they had to sleep on the floor at Newark Airport. Several human errors—left...
An unusual cause of shoulder pain

An unusual cause of shoulder pain

  A woman in Montréal underwent a total hysterectomy for ovarian cancer back in March, and from the moment she woke up from anesthesia, had shoulder pain “like being stabbed with a knife.” After being told such pain was normal after surgery and eventually having her shoulder x-rayed and injected with cortisone, the real cause was found 2 months later. When an abdominal x-ray was taken, a 30 cm [about 1 foot] metal retractor was found. The shoulder pain was due to the retractor pressing on the diaphragm. A second operation was required to remove it. According to a CBC News story about the incident, the hospital where this took place “launched an investigation.” This is, of course, what hospitals do. Standard procedure in every hospital is to meticulously count the sponges, needles, and instruments used before the case begins, whenever items are added to the operative field, and twice before the case ends. The Montréal hospital staff apparently did so. The Québec Health Minister said, “Everything is counted and recounted at the end to make sure that nothing stays inside the patient, and in this case it was the recounting process that didn’t work.” See, the “process” was to blame. I disagree. A major cause of retained objects in surgery is human error—specifically mistakes in counting. A New England Journal of Medicine study by Gawande et al found “Of the many cases of retained foreign bodies in which counts were performed, 88 percent involved a final count that was erroneously thought to be correct.” Significant risk factors for retention of a foreign body in the NEJM series included...
“Brazilian butt lift” takes another life

“Brazilian butt lift” takes another life

Last year I blogged about a cosmetic surgeon in Florida named Osak Omulepu who had several bad patient outcomes resulting in the Florida Board of Health prohibiting him from performing Brazilian butt lifts. A lot has happened since then. On June 1st of this year, Lattia Baumeister, a 30-year-old mother of six from Illinois, died of fat emboli after a Brazilian butt lift performed by none other than Dr. Omulepu. Wait, hadn’t he been banned from doing that procedure? According to the Miami Herald, “Florida officials had tried three times since February 2016 to stop Omulepu from performing liposuction and a fat transfer procedure to the buttocks known as a ‘Brazilian butt lift,’ his self-declared specialty. Each time, the same state appellate court in Tallahassee restored Omulepu’s practicing privileges under his Florida medical license.” Ironically on June 1st, the appeals court had denied the state board’s request to stop him from doing liposuction procedures while his appeal was in progress. His lawyer had argued that because he almost exclusively performed liposuction, stopping him from doing that procedure would have constituted a “de facto suspension” of his license. Four days after Baumeister’s death, the court ordered Omulepu, who is not board-certified in any surgical specialty, to stop performing plastic surgery, but did not lift his license stating that “a board-certified physician must be present for any other medical procedures” he does. A ruling from the court on the state’s continuing efforts to remove the doctor’s license is pending. The clickorlando.com website reported that Omulepu has had 12 complaints registered with the state. When I blogged about him last year, I...
Nonadherence to medications: Who’s to blame?

Nonadherence to medications: Who’s to blame?

No foundations or patient advocate groups are promoting awareness of nonadherence. There are no colored ribbons, no fundraising walks, runs, jogs, trots, or swims. The New York Times says nonadherence to prescribed medications is “an out-of-control epidemic” in the US and quotes a review in Annals of Internal Medicine, which found “20-30% of medication prescriptions are never filled, and approximately 50% of medications for chronic illness are not taken as prescribed.” For example, “a third of kidney transplant patients don’t take their anti-rejection medications, 41% of heart attack patients don’t take their blood pressure medications, and half of children with asthma either don’t use their inhalers at all or use them inconsistently.” Many reasons for nonadherence were discussed—aversion to chemicals, a desire to do things “naturally,” pills represent reminders of sickness, self-experimentation with stopping medications and noticing no change in perceived health, and drug costs. Another Times piece discussed a study showing that Medicare patients fail to adhere to prescriptions for high-intensity statins. At 6 months after discharge, 58.9% were taking their high-intensity statins as prescribed, and at 2 years, the percentage had fallen to 41.6%. The study involved almost 30,000 Medicare beneficiaries who all had Medicare fee-for-service and pharmacy benefits coverage. In addition to the reasons listed above, some say the problem must be because doctors are not to educating their patients about the importance of taking their medications. From the Times: The senior author of the statin study, Dr. Robert S. Rosenson, a professor of medicine at the Icahn School of Medicine at Mt. Sinai, said, “Health care providers have an obligation to educate the patient. We...
Transgastric appendectomy: The answer to a question no one is asking

Transgastric appendectomy: The answer to a question no one is asking

  No one really wants to know if taking out an inflamed appendix using an endoscope passed through the mouth, esophagus, and stomach is a safe operation. But some German surgeons have published another paper on the subject. Their first paper, which I critiqued in 2013, was what is known as a pilot study—kind of a “let’s see if this works at all” before doing more formal research. In that one, 15 patients underwent transgastric appendectomy with five significant complications. Undaunted, the investigators pressed on. The current paper, published ahead of print in the journal Surgery, is a nonrandomized comparison of standard 3-port laparoscopic appendectomy to hybrid transgastric appendectomy. The procedure is called “hybrid” because a small abdominal wall incision must be used to insert an instrument to facilitate visualization and ligation of the appendix. From October 2010 to May 2013, the investigators screened 273 patients with appendicitis and after patient refusals and exclusions for various criteria, transgastric appendectomy was offered to 65 patients. Of that group, 30 agreed to undergo the NOTES procedure, and 35 opted for standard laparoscopic appendectomy. The groups were similar in age, sex, and body mass index. The duration of surgery for the NOTES patients was 94.5 minutes compared to 69 minutes for the laparoscopic cohort, a statistically significant difference. The duration for both procedures far exceeds the norm of 20 to 40 minutes for a laparoscopic appendectomy in the US. NOTES patients did not tolerate a regular diet until postoperative day 2 vs. day 1 for the standard patients, a statistically significant difference. Although the median length of postoperative stay after surgery was...
System errors, human errors, and common sense

System errors, human errors, and common sense

  “It was a system failure.” That’s what United Airlines CEO Oscar Munoz said in an interview with ABC News about the recent incident involving the violent removal of a seated passenger from a plane. I’m not so sure. I have blogged many times about the tendency of hospitals and other organizations to blame mistakes on systems when human error is often the real cause. Here are a few examples. Delta Airlines allowed a nine-year-old boy to fly from Minneapolis to Las Vegas without a ticket or boarding pass. In the post, I pointed out that the system wasn’t the problem. Several humans failed to do their jobs in order for it to have happened. A 16-year-old patient suffered complications after he was given 38 antibiotic pills by a nurse who failed to question the order. 38 pills? She should have questioned the order but put too much trust in the electronic medical record and its supposed infallibility. I once worked at a hospital where every mistake was blamed on the system. Corrective actions to the system had to be developed through endless root cause analysis meetings. In a post called “System failure often really means someone made a mistake,” I discussed several papers which found most medical errors were caused humans, not systems. Many people have missed the fact that the United flight from Chicago to Louisville was not simply overbooked. The problem arose when four members of a United crew who need to get to Louisville to staff a flight the following morning showed up at the airport. Every seat on what was the last flight to...
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