Nine days after my post wondering if the late Rep. John Murtha's death after an elective gallbladder surgery was a result of a preventable medical error, CNN and the Washington Post report that the Navy is now opening an investigation.
"The review is being conducted to determine if Murtha died due to a preventable surgical error and whether any action against those who performed the surgery is potentially warranted." according to the CNN article.
While this is good news, what I found rather disappointing was CNN's senior medical correspondent Elizabeth Cohen thoughts on how Murtha might have acted differently to avoid this unforseen outcome.
"You really have to be an aware and empowered patient because in those two days it's likely that he likely felt something that he felt some discomfort or felt a bit ill and, of course, we aren't trying to blame the patient but if you feel anything at all strange following a surgery you have to go back to that surgeon."
While I suspect she is trying to be helpful, the advice she offers isn't particularly meaningful. Who doesn't feel a little discomfort, feel strange, or a bit ill after having surgery? What other past life experience provides a reference point on whether this post-operative recovery will turn out fine or be completely disastrous?
The reason she would say such a thing is because our healthcare system is not as good as it must be in preventing medical errors and eliminating missed opportunities for prevention and screenings. Patients don't want to constantly worry about being an "aware and empowered patient". They don't want to be burdened with the responsibility of being vigilant for bad outcomes. They would rather can focus on healing and getting better.
Our healthcare system must continue to focus on improving patient safety.
So, in the end, was Murtha's death preventable? While I don't have any specifics of his case, my sense is that unfortunately his death was the result of a known risk and surgical complication and not due to gross incompetence or negligence. Let's be frank the Navy's review of Murtha's death is only because of his status as a very visible Congressman. Had this occurred to someone else, I doubt a death after gallbladder surgery would have received this level of scrutiny.
If this review is done objectively, then I don't expect anyone to be reprimanded or fired.
His death, however, does serve as important reminder. Only have surgery if it is absolutely necessary.
Showing posts with label John Murtha. Show all posts
Showing posts with label John Murtha. Show all posts
Sunday, February 21, 2010
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.
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.
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