Have you ever wondered how many Sacramento physicians actually admit in public any medical errors such as surgical mistakes? Are hospital and other medical errors on the rise in Sacramento? What’s being done about the 1,538 serious and preventable events reported by California hospitals for the fiscal year ended June 30, according to the article, Hospital Errors on the Rise | Sacramento Business Journal. There were 132 medical or hospital error incidents in the Sacramento region, averaging 11 a month.
Check out the local video news report by Sacramento’s KCRA TV (channel 3) reporters on Sacramento’s possible underreported medical mistakes. Critics Claim Medical Mistakes Under-Reported – Video – KCRA. Critics claim self-reporting of medical mistakes by hospitals is akin to having the fox watch the henhouse. Check out the San Diego Business Journal’s article, “Hospital Errors on the Rise | Sacramento Business Journal.”
Usually it’s the Sacramento patients that talk about medical errors to friends and relatives, like the gauze pad left inside a certain female’s body after giving birth. The doctor apologized to the patient after a nurse removed the gauze that had been stuffed inside the woman’s birth canal and remained there for a few days after she gave birth, until it came time to go home from the hospital.
The patient made no big deal out of the issue and accepted the doctor’s apology, but did tell relatives about it. She still goes to the same doctor. A lot of worse surgical errors have been made that actually made the public newspapers and TV media. But really, how many doctors make it public when it happens and the media is not told? Do you think medical mistakes are under reported in Sacramento or anywhere else?
Check out the February 21, 2011 Johns Hopkins Medical Institutions news release, “Famed neurosurgeon’s century-old notes reveal ‘modern’ style admission of medical error.” The news release notes that “neurosurgeon Harvey Cushing’s records show copious acknowledgement of medical errors that helped fuel advancements.”
The current focus on medical errors isn’t quite as new as it seems. A Johns Hopkins review of groundbreaking neurosurgeon Harvey Cushing’s notes, made at the turn of the last century, has turned up copious documentation of his own surgical mishaps as well as his suggestions for preventing those mistakes in the future, according to that news release.
Authors of the article, published in the February 2011 Archives of Surgery, suggest that such open documentation may have played an important role in spurring groundbreaking medical treatment advances in Cushing’s era — and could have the same effect today. Read the study’s abstract, “Harvey Cushing’s Open and Thorough Documentation of Surgical Mishaps at the Dawn of Neurologic Surgery.”
“Acknowledging medical errors is evidently something that doctors identified early on as critical to advancement a very long time ago,” says principal author Katherine Latimer, B.S., a medical student at the Johns Hopkins University School of Medicine, according to the EurekAlert! news release of February 21, 2011, “Famed neurosurgeon’s century-old notes reveal ‘modern’ style admission of medical error.”
Latimer and her colleagues scoured Johns Hopkins’ archives to locate operative notes covering 878 of Cushing’s patients. The notes, transferred decades ago to microfilm, covered the early years of Cushing’s career, from 1896 to 1912, at The Johns Hopkins Hospital. After deciphering the notes—a monumental task, the authors say, owing to Cushing’s poor handwriting, abbreviations, and pages crowded with notes of other physicians, too—the researchers selected 30 cases in which errors were clearly delineated.
The cases fell into categories of errors similar to those that plague doctors today, the authors said, classifying 11 of the cases as errors of judgment in which Cushing made the wrong choice during a surgery. One example: operating on the wrong side of a patient’s brain. Seventeen cases were identified as “human error,” mistakes in which Cushing revealed clumsy or careless behavior, such as dropping an instrument into a surgical wound. Three of the errors were considered equipment or tool oversights, such as the case in which a woman’s heavy bleeding left Cushing and his colleagues without enough wax, a substance used at the time to seal blood vessels.
Latimer and her colleagues say they were surprised by Cushing’s frank and copious documentation of his own shortcomings. His notes acknowledged mistakes that may have resulted in patients’ deaths, as well as those that didn’t seem to harm patients’ outcomes. They said the documentation took place in an era in which malpractice litigation was becoming a growing concern for doctors. Though malpractice penalties were substantially smaller in Cushing’s day, lawsuits presented a serious risk for physicians’ reputations, the authors noted.
The authors also emphasized that Cushing practiced in a time of enormous surgical innovation. For example, patient mortality from surgical treatment of brain tumors fell from 50 percent to 13 percent during his career. While some of this jump ahead was due to improving technology, the authors propose that part of the reason was open documentation of errors, which helped Cushing and other surgeons develop fixes to avoid them.
“People are human and will make medical mistakes,” says Latimer, “but being vigilant about your own shortcomings is critical to improving. To keep medical innovation flowing, we need to strive to maintain this same vigilance today.”
Alfredo Quinones, M.D., associate professor of neurosurgery at the Johns Hopkins University School of Medicine and senior author of the study, adds that today’s medical errors continue to have a tremendous impact on patients and their families. “Recognizing errors and reporting them can help us greatly improve medicine,” he says. “After all, we are all working towards the same goal: better patient care.” For further information, check out the Archives of Surgery abstract of the article or the Johns Hopkins Medical Institutions website.
