Authors: Atul Gawande
Though anesthesiology has unquestionably taken the lead in analyzing and trying to remedy “systems” failures, there are signs of change in other quarters. The American Medical Association, for
example, set up its National Patient Safety Foundation in 1997 and asked Cooper and Pierce to serve on the board of directors. The foundation is funding research, sponsoring conferences, and attempting to develop new standards for hospital drug-ordering systems that could substantially reduce medication mistakes—the single most common type of medical error.
Even in surgery there have been some encouraging developments. For instance, operating on the wrong knee or foot or other body part of a patient has been a recurrent, if rare, mistake. A typical response has been to fire the surgeon. Recently, however, hospitals and surgeons have begun to recognize that the body’s bilateral symmetry makes these errors predictable. In 1998, the American Academy of Orthopedic Surgeons endorsed a simple way of preventing them: make it standard practice for surgeons to initial, with a marker, the body part to be cut before the patient comes to surgery.
The Northern New England Cardiovascular Disease Study Group, based at Dartmouth, is another success story. Though the group doesn’t conduct the sort of in-depth investigation of mishaps that Jeffrey Cooper pioneered, it has shown what can be done simply through statistical monitoring. Six hospitals belong to this consortium, which tracks deaths and other bad outcomes (such as wound infection, uncontrolled bleeding, and stroke) arising from heart surgery and tries to identify the various risk factors involved. Its researchers found, for example, that there were relatively high death rates among patients who developed anemia after bypass surgery, and that anemia developed most often in small patients. The solution used to “prime” the heart-lung machine caused the anemia, because it diluted a patient’s blood, so the smaller the patient (and his or her blood supply) the greater the effect. Members of the consortium now have several promising solutions to the problem. Another study found that a group at one hospital had made mistakes in “handoffs”—say, in passing preoperative lab results to the people in the operating room. The study group solved the problem by developing a pilot’s checklist for all patients coming to the OR. These
efforts have introduced a greater degree of standardization, and so reduced the death rate in those six hospitals from 4 percent to 3 percent between 1991 and 1996. That meant two hundred and ninety-three fewer deaths. But the Northern New England cardiac group, even with its narrow focus and techniques, remains an exception; hard information about how things go wrong is still scarce. There is a hodgepodge of evidence that latent errors and systemic factors may contribute to surgical errors: the lack of standardized protocols, the surgeon’s inexperience, the hospital’s inexperience, inadequately designed technology and techniques, thin staffing, poor teamwork, time of day, the effects of managed care and corporate medicine, and so on and so on. But which are the major risk factors? We still don’t know. Surgery, like most of medicine, awaits its Jeff Cooper.
It was a routine gallbladder operation, on a routine day: on the operating table was a mother in her forties, her body covered by blue paper drapes except for her round, antiseptic-coated belly. The gallbladder is a floppy, finger-length sac of bile like a deflated olive-green balloon tucked under the liver, and when gallstones form, as this patient had learned, they can cause excruciating bouts of pain. Once we removed her gallbladder, the pain would stop.
There are risks to this surgery, but they used to be much greater. Just a decade ago, surgeons had to make a six-inch abdominal incision that left patients in the hospital for the better part of a week just recovering from the wound. Today, we’ve learned to take out gallbladders with a miniature camera and instruments that we manipulate through tiny incisions. The operation, often done as day surgery, is known as laparoscopic cholecystectomy, or “lap chole.” Half a million Americans a year now have their gallbladders removed this way; at my hospital alone, we do several hundred lap choles annually.
When the attending gave me the go-ahead, I cut a discreet inch-long semicircle in the wink of skin just above the belly button. I dissected
through fat and fascia until I was inside the abdomen and dropped into place a “port,” a half-inch-wide sheath for slipping instruments in and out. We hooked gas tubing up to a side vent on the port, and carbon dioxide poured in, inflating the abdomen until it was distended like a tire. I inserted the miniature camera. On a video monitor a few feet away, the woman’s intestines blinked into view. With the abdomen inflated, I had room to move the camera, and I swung it around to look at the liver. The gallbladder could be seen poking out from under the edge.
We put in three more ports through even tinier incisions, spaced apart to complete the four corners of a square. Through the ports on his side, the attending put in two long “graspers,” like small-scale versions of the device that a department store clerk might use to get a hat off the top shelf. Watching the screen as he maneuvered them, he reached under the edge of the liver, clamped onto the gallbladder, and pulled it up into view. We were set to proceed.
Removing the gallbladder is fairly straightforward. You sever it from its stalk and from its blood supply, and pull the rubbery sac out of the abdomen through the incision near the belly button. You let the carbon dioxide out of the belly, pull out the ports, put a few stitches in the tiny incisions, slap some Band-Aids on top, and you’re done. There’s one looming danger, though: the stalk of the gallbladder is a branch off the liver’s only conduit for sending bile to the intestines for the digestion of fats. And if you accidentally injure this main bile duct, the bile backs up and starts to destroy the liver. Between 10 and 20 percent of the patients to whom this happens will die. Those who survive often have permanent liver damage and can go on to require liver transplantation. According to a textbook, “Injuries to the main bile duct are nearly always the result of misadventure during operation and are therefore a serious reproach to the surgical profession.” It is a true surgical error, and, like any surgical team doing a lap chole, we were intent on avoiding this mistake.
Using a dissecting instrument, I carefully stripped off the fibrous white tissue and yellow fat overlying and concealing the base of the gallbladder. Now we could see its broad neck and the short stretch where it narrowed down to a duct—a tube no thicker than a daisy stem peeking out from the surrounding tissue, but magnified on the screen to the size of major plumbing. Then, just to be absolutely sure we were looking at the gallbladder duct and not the main bile duct, I stripped away some more of the surrounding tissue. The attending and I stopped at this point, as we always do, and discussed the anatomy. The neck of the gallbladder led straight into the tube we were eyeing. So it had to be the right duct. We had exposed a good length of it without a sign of the main bile duct. Everything looked perfect, we agreed. “Go for it,” the attending said.
I slipped in the clip applier, an instrument that squeezes V-shaped metal clips onto whatever you put in its jaws. I got the jaws around the duct and was about to fire when my eye caught, on the screen, a little globule of fat lying on top of the duct. That wasn’t necessarily anything unusual, but somehow it didn’t look right. With the tip of the clip applier, I tried to flick it aside, but instead of a little globule, a whole layer of thin unseen tissue came up, and, underneath, we saw that the duct had a fork in it. My heart dropped. If not for that little extra fastidiousness, I would have clipped off the main bile duct.
Here was the paradox of error in medicine. With meticulous technique and assiduous effort to insure that they have correctly identified the anatomy, surgeons need never cut the main bile duct. It is a paradigm of an avoidable error. At the same time, studies show that even highly experienced surgeons inflict this terrible injury about once in every two hundred lap choles. To put it another way, I may have averted disaster this time, but a statistician would say that,
no matter
how hard I tried, I was almost certain to make this error at least once in the course of my career.
But the story doesn’t have to end here, as the cognitive psychologists and industrial error experts have demonstrated. Given the
results they’ve achieved in anesthesiology, it’s clear that we can make dramatic improvements by going after the process, not the people. But there are distinct limitations to the industrial cure, however necessary its emphasis on systems and structures. It would be deadly for us, the individual actors, to give up our belief in human perfectibility. The statistics may say that someday I will sever someone’s main bile duct, but each time I go into a gallbladder operation I believe that with enough will and effort I can beat the odds. This isn’t just professional vanity. It’s a necessary part of good medicine, even in superbly “optimized” systems. Operations like that lap chole have taught me how easily error can occur, but they’ve also showed me something else: effort does matter; diligence and attention to the minutest details can save you.
This may explain why many doctors take exception to talk of “systems problems,” “continuous quality improvement,” and “process re-engineering.” It is the dry language of structures, not people. I’m no exception: something in me, too, demands an acknowledgment of my autonomy, which is also to say my ultimate culpability. Go back to that Friday night in the ER, to the moment when I stood, knife in hand, over Louise Williams, her lips blue, her throat a swollen, bloody, and suddenly closed passage. A systems engineer might have proposed some useful changes. Perhaps a backup suction device should always be at hand, and better light more easily available. Perhaps the institution could have trained me better for such crises, could have required me to have operated on a few more goats. Perhaps emergency tracheostomies are so difficult under any circumstances that an automated device could have been designed to do a better job.
Yet although the odds were against me, it wasn’t as if I had no chance of succeeding. Good doctoring is all about making the most of the hand you’re dealt, and I failed to do so. The indisputable fact was that I hadn’t called for help when I could have, and when I plunged the knife into her neck and made my horizontal slash my best was not good enough. It was just luck, hers and
mine, that Dr. O’Connor somehow got a breathing tube into her in time.
There are all sorts of reasons that it would be wrong to take my license away or to take me to court. These reasons do not absolve me. Whatever the limits of the M & M, its fierce ethic of personal responsibility for errors is a formidable virtue. No matter what measures are taken, doctors will sometimes falter, and it isn’t reasonable to ask that we achieve perfection. What is reasonable is to ask that we never cease to aim for it.
“A
re you going to the convention?” the attending asked.
“Me?” I said. He was speaking of the upcoming American College of Surgeons convention. It had never occurred to me that I could go.
Conventions are big deals in medicine. My doctor parents have gone to their conventions faithfully for thirty years, and I vaguely remembered, from the occasions in my childhood when they had brought me along, how dense and enormous and exciting they seemed. As a resident, I had gotten used to the operating schedule suddenly emptying out each mid-October, when the faculty surgeons packed off to their annual convention en masse. But we residents would stay behind, along with a skeleton crew of unlucky attendings (usually the most junior ones), to manage the trauma cases and other random emergencies that still came in. A lot of the time was spent kicked back in the residents’ lounge—a dim musty den with flat brown carpeting, a moldering couch, a broken rowing machine, empty soda cans, and two televisions—watching end-of-year baseball on the one television that worked and eating take-out Chinese.
Each year, however, a few senior residents have gotten to tag along
to
the convention. And in my sixth year I was told that I had
now reached the stage in training that allowed me to be one of them. The hospital turned out to have a small fund that would pay for the trip. Within a few days I had a plane ticket to Chicago, a reservation at the Hyatt Regency, and an admission badge for the eighty-sixth annual Clinical Congress of Surgeons. It was not until I was at twenty-seven thousand feet in a Boeing 737 somewhere over New Hampshire, my wife settled back home for a week in sole possession of our three children, that I finally thought to wonder what on earth one goes to these things for.
I arrived at Chicago’s massive McCormick Place convention center to find that I was but one of nine thousand three hundred and twelve surgeons in attendance. (A daily newspaper just for the convention reported the daily count.) The building looked like an airport terminal and felt like Penn Station at rush hour. I took an escalator up to a deck above the main hall and looked out upon the sprawl. There were, it struck me, nearly as many people milling around this one building talking surgery as live in the Ohio towns around where I grew up. The surgeons—mostly men and middle-aged, a little shlumpy, in navy jackets, wrinkled shirts, conservative ties—were gathering in clumps of two and three, everyone smiling, shaking hands, catching up. Nearly all wore glasses and stood with a slight operating-table stoop. A few stood alone, leafing through their program books, deciding what to see and do first.
Each of us, upon arriving, had been handed a three hundred and eighty-eight–page schedule of programs we could attend—from a course that first morning on how to do advanced image-guided breast biopsies to a panel presentation on the sixth and final day entitled “Office-Based Treatment of Ano-Rectal Disease—How Far Can We Go?” Eventually, I too settled down with my book, diligently scanning it page by page and circling in blue ballpoint pen anything that caught my eye. This was, I decided, the place where the new and better could be found—the place where the more
nearly perfect was being taught—and it seemed almost an obligation to attend as much of the proceedings as I could. Before long my book was blue with circles. The first morning alone, I had more than twenty instructive-looking programs to choose from. I debated going to a lecture on the proper way to dissect a neck or a session on new advances in managing gunshot wounds to the head, but finally decided on a panel debate about the best way to repair hernias of the groin.