Monday, February 8, 2010

Could Rep. John Murtha Have Died from a Medical Error or Omission?

While the news reports that Representative John Murtha of Pennsylvania died after complications from gallbladder surgery, the question no one is asking is whether his death was a preventable one or simply an unfortunate outcome. According to the Washington Post, Murtha had elective laproscopic gallbladder surgery performed at the Bethesda Naval Hospital and fell ill shortly afterwards from an infection related to his surgery.

He was hospitalized to Virginia Hospital Center in Arlington, Virginia, to treat the post-operative infection. His care was being monitored in the intensive care unit (ICU), a sign which suggests that not only was the infection becoming widespread but also that vital organ systems were shutting down.

Was his death preventable or simply unavoidable? One reference notes that when gallbladder surgery is performed electively that "the mortality rates are very low. (Even in the elderly, mortality rates are only 0.7 - 2%.)" Perhaps Murtha was one of the unlucky 2 out of 100 to have died from this elective surgery.

It is also equally likely that he died of a medical error or omission. As Dr. Atul Gawande notes in his newest book - The Checklist Manifesto - a simple list helped prevent less than optimal surgical outcomes. One item on the list is whether or not IV antibiotics were given at the time the surgeon begins the opening incision. You would think this would be obvious, yet in the operating room, there is a surgical team which as a group is responsible for the patient's care. Do they work as a highly functioning team? Are there clear lines of communications between the surgeon, anesthesiologist, nurses, and surgical techs? Sadly, communications are not as clear as they need to be. As Gawande notes, a simple two minute checklist not only forced communications (something as basic as an introduction to the surgical team - "Hi, I'm Dr. Gawande general surgeon") but also verified that critical tasks were completed. As a result, the checklist decreased the complication rates by 36 percent and death rate by half. Disappointingly only 20 percent of American hospitals have adopted these types of checklists.

The Leapfrog Group rates hospitals on their processes to keep patients safe. Bethesda Naval Hospital being a government institution isn't listed and is not part of the survey. (Leapfrog Group was founded by large employers, who purchase health insurance, to evaluate the care their employees receive from hospitals).

Virginia Hospital Center, where Murtha was hospitalized, didn't submit any information either even though it is listed in the Leapfrog Group database. Specifically, Virginia Hospital Center declined to respond to the survey on how they are doing to keep medical errors from occurring. Questions include whether there is adequate ICU staffing, processes to reduce ICU infections, and steps to prevent harm. Gawande notes in his earlier New Yorker piece that even intensive care units errors of omission and missed opportunities happen which can be avoided with checklists.

In other words due to lack of transparent information, both hospitals are black boxes - Bethesda Naval Center because it is a government run hospital and Virginia Hospital Center because it didn't submit any data. There is a good chance that Murtha's death was possibly avoidable. This doesn't mean that doctors aren't working hard or trying to do their best. I believe that getting medical care must be as safe as it is humanly possible. Having witnessing near misses in medical care with my family and understanding what it takes to make patient safety as routine as other highly reliable organizations, I recognize that there is still much to do.

In the mean time, what does this mean for you? Surgery is never routine. If you need to have an operation, check out the hospital and how it rates to keep you safe at The Leapfrog Group. Not listed there? See if you can get surgery at a hospital that is recognized by Leapfrog.

3 comments:

John Beatty said...

Thanks for this piece. I've been scratching my head about this one if it's really a "nicked instine".

I remember several years ago there was a compelling presentation at Stanford about robotic surgical systems (http://ecorner.stanford.edu/authorMaterialInfo.html?mid=1566). I see now that over 1,000 of the da Vinci robots have been sold (http://en.wikipedia.org/wiki/Da_Vinci_Surgical_System), and that the system is marketed towards cholecystectomies (http://www.davincisurgery.com/general-surgery/davinci-procedures/cholecystectomy.html). I'm curious if this "nicked intestine" would have likely been avoided if using a robotic surgical system rather than the standard laparoscopic technique, why a robotic system wasn't used on a Congressperson if it's markedly better, etc. Of course, maybe there are simpler/cheaper things than robotics that could have prevented this, but the robotic machines are set up to prevent exactly this kind of error to my understanding.

Thanks for any insight.

Veronica Waks MD, ND said...

i see you are for "check list" .i love it. do it in my practice all the time.

bethesda pharmacy said...

You actually have a nice question on your title. I think this is really a great topic to tackle. Btw, found your blog today.

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