Take the issue of antibiotics before surgery. Studies show that if an antibiotic is administered within one hour prior to surgery (the initial cutting), it may cut the rate of infection by 50 percent or more. However, “a major national survey taken in 2005 found that barely more than half of the patients got the dose of antibiotics they were supposed to receive within one hour of the first cut.” That is from an excellent book on how to protect yourself in the medical system by Patrick Malone titled The Life You Save: Nine Steps to Finding the Best Medical Care – and Avoiding the Worst. That’s just one of a ten-part checklist, so there is abundant chance of error, and abundant possibility of preventing potentially deadly errors. According to the World Health Organization, half of all harmful events related to surgery are preventable.
The best checklist for surgery I could find was prepared by the World Health Organization (WHO). That checklist was revised and restated by Malone in his book, which is valuable reading on many healthcare topics. That material will be referred to henceforth as the WHO Checklist. It is a far superior to a checklist prepared by the Joint Commission as part of its “SpeakUp” program, designed to make for more educated and informed patients. The SpeakUp Guide publication on informing surgical patients is entitled “Take an Active Role in Your Surgical Procedures,” a document often adapted by hospitals for their own use. In this column I compare the WHO checklist with one based on the Joint Commission’s work. That will be referred to as the Commission Checklist.
First, I’ll dispose of the Commission Checklist as weak and inadequate. It simply doesn’t provide the kind of information you need. For example, it omits the antibiotic requirement, something a patient can discuss with the surgeon in advance and then make sure the appropriate antibiotic is administered at the proper time before surgery. Another example of the weakness of the Commission Checklist is that it doesn’t advise the patient on what to do if the checklist is not complied with. Malone, in his book, gives concrete advice on what to do if the Checklist is ignored. He writes, “Each item on this lists needs to be checked off before you are knocked out. If they don’t happen, even one of them, or seem to happen in a helter skelter way, you should consider postponing the surgery. Also remember you may not be up to enforcing all those items yourself; that’s another reason to have an advocate with you at all times…” I’d go a little further than postponing surgery. If the hospital can’t handle the checklist, I wouldn’t give them another chance to screw-up, but would look around for another hospital and perhaps another surgeon. Don’t be embarrassed or hesitant to not go forward with a surgical scenario that may be fatal.
The Commission Guide is also weak on the need of a patient advocate. Here’s what it has to say on that: “Ask someone you trust to take you to and from the surgery facility [and] be with you at the hospital or surgery facility. This person can assist with your care and help provide support.” Malone’s formulation of the WHO Guide is much stronger, calling for an advocate – perhaps a friend, relative, or other person – who to the extent of his competence, can serve as your advocate, protector, enforcer, and defender, especially when you might be unconscious or otherwise unable to make a decision. The advocate can also back you up, and make sure you don’t forget important questions and make sure others don’t forget to take essential action. I have acted as an advocate on many occasions, and it is a rare, rare hospital day when an informed advocate won’t prevent multiple errors, which might have disastrous consequences if not prevented. A knowledgeable and assertive advocate may be hard to find, but you want the most able one you can find.
When I’ve served as an advocate for patients, I’ve noticed there’s an epidemic of failure to wash hands before patient contact (as documented by an ever-flowing stream of medical literature). There’s an epidemic of failure to clean stethoscopes with an alcohol swab before using them on patients. There’s an epidemic of proper gloving, which must be combined with hand washing for full protection. There are many healthcare providers who erroneously think wearing a pair of gloves eliminates the need for hand washing. There’s also an epidemic of failure to properly swab (sterilize with alcohol or other disinfectant) an injection site before injecting. And if they don’t do the most basic things properly such as hand washing, you can be sure they’ll be mistakes in abundance on the more complicated issues.
Here’s the WHO Checklist as stated and modified by Malone in his book. For more details see his book or the Commission’s web site. The Commission also has a manual for implementation of checklist that can be accessed on the Internet. After its checklist, it notes: “The checklist is not intended to be comprehensive. Additions and modifications to fit local practice are encouraged.”
THE WORLD HEALTH ORGANIZATION SAFE-SURGERY CHECKLIST.
1. “Someone should confirm with you your identify, the type of procedure you’re having, the site of the surgery on your body, and your consent to have it done.
2. The surgeon should mark the operative site with her initials using a permanent marker-type pen [to help prevent the too common malpractice of cutting off the wrong limb, removing the wrong kidney, etc.).
3. The anesthesia equipment needs to be inspected to make sure everything is working and they have enough supplies of emergency medications. (You are unlikely to notice this unless you ask the anesthesia provider.)
4. A pulse oximeter should be placed on one of your fingers and should be functioning. [When someone puts it on your finger, ask what your oxygen saturation is, to make sure someone looks at the oximeter and makes sure it is functioning.]
5. Someone should ask you if you are allergic to any drugs.
6. Have you ever had trouble being anesthetized? [That may mean you may have a difficult airway, causing difficulty in putting in a tube for breathing; the surgical team should know about that.]
7. Does the surgery pose a risk of losing more than half a liter of blood? [If so, special precautions have to be taken, like starting large-bore intravenous lines for transfusions and other fluids.]
8. For most operations, you should receive a dose of preventive antibiotic within one hour before your skin is cut [as discussed earlier].
9. Important X-rays films need to be in the operating room. [This can help prevent such mistakes as wrong-organ removal.]
10.A strategy for preventing deadly blood clots in the days and weeks after surgery need to be decided on before surgery, because the most effective measures work better the sooner they are started.”
The safe-surgery checklist, assumes you have already done your due diligence in finding the right surgeon to do the procedure at the right hospital. It also assumes you have obtained a second opinion, and taken other steps, subjects perhaps of a future column.
(Herb Denenberg has served as insurance commissioner of Pennsylvania, as a commissioner of the Pennsylvania Public Utility Commission, and as the Loman Professor of Insurance at the Wharton School of the University of Pennsylvania. He was elected to the Institute of Medicine and has frequently testified before Congress on healthcare and insurance issues, and has published extensively on those matters. You can contact Herb at advocate@thebulletin.us.)
Herb Denenberg is a former Pennsylvania Insurance Commissioner, professor at the Wharton School, and
Pennsylvania Public Utility Commissioner. He is a member of the Institute of Medicine of the National
Academy of Sciences and is a board member of the Center for Safe Medication Use. He is an adjunct
professor of insurance and information science and technology at Cabrini College. You can write Herb
at POB 7301,St. Davids, PA e-mail him at hdenenberg@aol.com or reach him at his two Web sites:
thedenrep_archive.org or denenbergsdump.org