ARTICLE: Preventing Medical Mistakes

Reported January 11, 2008

*A Los Angeles hospital removes the healthy testicle from a man undergoing surgery for testicular cancer.

*A 12-year old boy goes into the operating room for routine hernia surgery at a Midwestern hospital—an error with anesthesia leaves him with brain damage

*A Rhode Island hospital performs brain surgeries on three different patients over a period of less than a year, each time operating on the wrong side of the brain.

The Institute of Medicine estimates that 98,000 U.S. patients die each year in health care settings due to medical mistakes; others estimate the numbers may be as high as 145,000.

For the last seven years, a Memphis-based company run by pilots, former astronauts, physicians and risk managers has been tackling the problem of medical mistakes, one hospital at a time. Steve Harden, pilot and founder/CEO of the for-profit company, called Lifewings Partners, says the same principles that keep pilots and their passengers safe in the air can be used to prevent mistakes and improve safety in hospitals and other medical facilities. “We’re in it for patient safety,” says Harden, who adds that, to date, more than 70 medical facilities have used their services.

Lifewings has a five-step program that involves changing the hospital procedures and communication issues that can lead to mistakes, training physicians and nurses to work better as a team, also setting up checklists for standard operating procedures and measurements to track outcomes.
Harden cites a hospital in the Southeastern U.S. that went from having a “wrong surgery” once every 60 days, to a track record that logged more than 600 days without a single such incident.

“Health care is more safety and quality conscious than it’s ever been,” Harden says. “As long as health care is growing and more people are using it, the chance for mistakes will continue to increase, unless some fairly fundamental changes are made in how the health care teams work together.”

“The thing I tell people is not all hospitals are created equal,” Harden observes. “Just because a hospital has a great reputation for cutting edge medicine doesn’t necessarily mean the hospital is the safest place to go for routine procedures.”

For patients planning for an upcoming surgery or a hospital stay, Harden has these tips:

1. Get online—go to www.healthgrades.com, www.jointcommission.org, or www.CMS.gov for publicly reported data on safety before you’re admitted;

2. Ask your doctor if the hospital has a team training program and uses checklists and other safety tools like standard operating procedures.

3. Ask a professional. Harden says doctors usually know which facility has the best safety record and quality outcomes, so ask your doctor where he/she would go if he were having the same surgery.

Source: Steven Harden, CEO and Founder of Lifewings Partners

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