As reported by The Washington Post, a new report by a hospital accreditation body estimates that so-called wrong site surgeries take place 40 times each week in the nation’s hospitals.
Wrong site surgeries are operations that take place on the wrong part of the body, such as amputations of healthy limbs, back surgeries that are performed on the wrong vertebrae, etc.
Wrong site surgeries are so common in fact that one in four orthopedic surgeons will make a wrong site error in their careers, according to the American Academy of Orthopaedic Surgeons.
The tragedy is that wrong site surgeries are among the most preventable kind of medical malpractice. Pre-surgery “timeouts” where the surgical team reviews the surgery, including surgical site, have been shown to dramatically reduce the incidence of wrong site surgery. In seventy-two percent of wrong site surgeries, the surgical team was found not to have stopped for a timeout.
And yet surgeons are resistant to adopting universal timeouts.
Perhaps surprising to a lot of tort reformers, only one-third of wrong site surgeries result in a medical malpractice claim. In fact, the wrong site involving Dr. Peter Ring of Boston (which we blogged about last year) never resulted in a medical malpractice lawsuit being filed, perhaps because of the conspicuous bravery and honesty of Dr. Ring, who bucked the medical system’s code of silence and used his wrong site surgery as a teachable moment.
As commendable as Dr. Ring’s conduct was, however, we need more than surgeons who are humble enough to publicly acknowledge their errors. We need surgeons who are willing to adopt the proven tactics – such as surgical timeouts and checklists – that can help eradicate wrong site surgeries.

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The Massachusetts legislature is weighing a bill that would give patients the right to have their surgery videotaped if they paid for the recording. Hospitals that refused to allow videotaping would face a $10,000 fine.
The bill had a hearing Tuesday before the Public Health Commission.
Personally, I think that in many surgeries the videos would be of little value in proving medical malpractice because so much of surgery requires working in tight confines that cameras can’t peer into.
But the psychological effect of recording may prompt surgeons to be more attentive and courteous, thus contributing to patient safety.

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Autopsies are a routine part of hospital deaths, right? Well, actually, no. Today autopsies are only performed in five percent of hospital deaths, down from over sixty percent 40 years ago.
As the incomparable philosopher/economist Robin Hanson notes at Overcomingbias.com, would we let it slide if only five percent of airline crashes were investigated?
Hanson argues that hospitals don’t want autopsies to be performed because they reveal too many doctor errors. According to a 1998 article published in The Journal of the American Medical Association, autopsy results show that doctors misdiagnose the cause of death at least 40 percent of the time. Hanson asks, “Could there be any clearer evidence that docs care more about getting paid than about healing patients, yet the public can’t bring itself to imagine docs are that selfish?”
I wholeheartedly agree with Hanson that the medical profession is not seriously committed to studying and learning from its mistakes. If it were, it would follow the model of the aviation industry and adopt the same kind of safety principles that the aviation industry has implemented.
But I disagree with Hanson that the medical profession’s atavistic impulses for self-preservation are the reason we’ve seen this dropoff in autopsies. I think we don’t get autopsies because insurers don’t pay for them. Private insurers generally do not pay for them and Medicare never pays for them because, under Medicare regulations, a dead patient does not meet the statutory definition of a “beneficiary.”
If we paid for autopsies, we’d get them done.
Autopsies are terribly important. It was autopsies that first made doctors realize that smokers were dying of lung cancer.
So what should we be doing? A lot of libertarian-leaning commentators (including liberals like Matt Yglesias) have been urging us to relax or abolish professional licensure requires that jack up the prices of services from hair salons to dental hygience to medicine.
I think autopsies are a perfect candidate for a procedure we should allow non-licensed professionals to perform. After all, what’s the worst harm that you can do to the person being autopsied? Kill them?
Let’s start doing autopsies again. We can do them at low cost and obtain all the benefits for public health.

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If you had asked me last week to define “nocturnist,” I would’ve guessed, “A musical composer who writes nocturnes. For example, Chopin or Debussey.”
But, as Kaiser Health News reports, a nocturnist is actually a member of a new medical specialty – a doctor who works exclusively nights at a hospital. You can think of a nocturnist as the nighttime counterpart of a hospitalist, that relatively new breed of doctor who practices exclusively at a hospital.
Hospitals are hiring nocturnists to reduce the nighttime incidence of medical malpractice. Nighttime can be an especially dangerous time for hospital patients: not only do hospitals tend to run a skeleton staff at night, but many of the doctors who are on duty (younger residents who work long hours) can be fatigued at nighttime.
The research data starkly illustrate how dangerous short staffs battling fatigue can be to patients. According to a 2008 study by the American Medical Association, hospital patients who suffer nighttime heart attacks are 50 to 70 percent less likely to survive than patients who have their heart attacks during the daytime, when medical staff are bright-eyed and bushy-tailed.
My guess is that hospitals’ use of nocturnists will reduce medical malpractice. Three months ago, we blogged about a new obstetric patient safety program that reduced medical malpractice by 99 percent in New York hospitals that participated. One of the main techniques that these New York obstetrics wards employed was the hiring of a “laborist,” an obstetrician who only worked nights and who was there to help the daytime obstetricians who might become fatigued during a labor that drags on for hours and hours.
We’ve also seen how minor fatigue — the typical fatigue that occurs over the course of an eight-hour daytime shift — can raise doctors’ risks of medical malpractice by twenty percent.
So let’s hear it for the nocturnists. And let’s hope they help the medical profession to cut back on the 100,000 deaths that occur annually due to medical malpractice.

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We all know that failing to take medicine as prescribed adds to the costs of our health care. For example, when someone fails to take a course of antibiotics to the end of the bottle and their infection flares back up, requiring another trip back to the doctor, that makes health care more expensive. And when someone forgets to take heart medication and has a heart attack, the costs of treating that heart attack are vastly greater than the cost of the bottle of pills that might have prevented it.
But just how much extra are we paying in health care costs because of people’s forgetfulness (and in some instances) and their willful failures to take medications as prescribed? According to two new studies (one by researchers at Harvard), failures to take prescribed medicines cost American health care $250 billion annually. (H/t USA Today). That’s an absolutely staggering number.
To give you some perspective on its size, last summer the journal Health Affairs published the most recent estimate of the annual cost of medical malpractice lawsuits. Its best guess was that medical malpractice lawsuits cost the health care system, directly and indirectly, $55 billion a year.
The cost of missed meds is five times as large as all of the costs of medical malpractice (including payouts to injured patients and malpractice insurance premiums), but you don’t hear people saying, “Hey, let’s do something about the problem of missed meds. We can save ourselves a fortune and, in the process, we won’t have to trample the rights of the people maimed, paralyzed and killed by medical malpractice.” Instead we hear the crusading tort reformers haranguing us that frivolous medical malpractice lawsuits are bankrupting the health care system (when all of the costs of medical malpractice, both direct and indirect, amount to less than two percent of health care spending).
If there’s any silver lining to learning that missed meds are costing us $250 billion annually, it’s that the problem has quick fixes. Studies show that when people get text message reminders to take their medications, they take them more reliably. Also, when patients are automatically enrolled in mail-order pharmacies, so that they don’t have to go to the pharmacy for their first script or for refills, many more patients take their meds.
I have an idea. Before we sacrifice the victims of medical malpractice on the altar of health care economy, why don’t we try text messages and see if that knocks down the cost of health care any?

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“We train, hire and pay doctors to be cowboys. But it’s pit crews people need.” – Dr. Atul Gawande
The commencement speaker who addressed this year’s graduating class at Harvard Medical should be a familiar figure to readers of this blog. It was one of the blog’s heroes – Dr. Atul Gawande – he of “checklist manifesto” and “health care cost conundrum” fame.
Although the tone of Dr. Gawande’s address was uplifting, it was not the typical commencement address larded with platitudes and bromides about life; instead Dr. Gawande delivered a clear clarion call to graduates about the future of medicine. Dr. Gawande stated that the task for this generation of doctors – the task which they must carry out if we are to improve health care and make it affordable – is to work together as members of pit crews work together, while applying data-driven best practices.
Dr. Gawande began his address which you can read here (h/t Cal Consumer Attorneys), by noting the explosion in the complexity of medicine in the last century, an explosion in knowledge and technology that outstripped the gains of all the past centuries of medicine combined.
In the 1930s, 40s and 50s, it was possible for doctors to tote around the whole of medical knowledge in their brains. Doctors were cowboys, lone wolfs, rather than collaborators. They didn’t need to know how to play nice or be part of a team because they didn’t need teammates; the sum total of the body of medical knowledge and treatment was at their fingertips, as it was so small.
But as medicine’s complexity has exploded, so too has the number of nurses, specialists and other health care patients involved in a patient’s care. In 1970, 2.5 nurses and doctors participated in the care of the average patient. By the 1990s, the number was more than 15.
As the number of moving parts in a patient’s care increases, the members of a patient’s health care team need to work together like a pit crew. Like pit crews, the members of a patient’s health care team should follow checklists – checklists that have been shown to reduce medical malpractice by forty-seven percent.
The principles doctors should follow in their checklists should be derived from data-driven research of best practices. As Dr. Gawande notes:

People in effective systems become interested in data. They put effort and resources into collecting them, refining them, understanding what they say about their performance.

When you study the data, you find that the most effective health care techniques are not the most expensive. And that fact means that we can afford health care without having to ration it. As Dr. Gawande notes:

The places that get the best results are not the most expensive places. Indeed, many are among the least expensive. This means there is hope–for if the best results required the highest costs, then rationing care would be the only choice. Instead, however, we can look to the top performers–the positive deviants–to understand how to provide what society most needs: better care at lower cost. And the pattern seems to be that the places that function most like a system are most successful.
By a system I mean that the diverse people actually work together to direct their specialized capabilities toward common goals for patients. They are coordinated by design. They are pit crews.

If, in twenty years time, you go to the hospital and the staff’s coordinated efforts resemble the coordinated efforts of a NASCAR pit crew more than a traditional hospital, chances are the care that you receive will be better. And cheaper.

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