Saturday, September 30, 2006

Reduce Medical Errors | Prevent Wrong Site Surgery |

Wrong site or wrong side surgery is vary rare. But if it occurs, it can ruin the surgeon's career.

What about the patient who was operated on the wrong site or side. It will be tremendously devastating.

It is better to prevent this from happening. How? And what is the best way?

I believe that every hospital in the United States must have some kind of protocol or guideline to prevent wrong site or wrong side surgery. One of the most common component of the protocol is to mark the surgical site or side in the operating room, before the start of the operation.

The protocols that I have seen or involved with were all excellent to prevent wrong side surgery but, in my opinion, contained one potential weakness. Let me explain by using a fictitious case to illustrate my point.

An elderly patient with history of mild cognitive impairment, with right inguinal hernia, sees his surgeon today. The diagnosis was confirmed. A right inguinal hernia is scheduled to be done three weeks later. This surgeon is a world renowned hernia surgeon. He usually will line up four or five hernia cases in a row.

On the fateful day, our patient above, woke up in the recovery room with a surgical wound and bandage on the left groin. The patient was supposed to have spinal anesthesia but it was not quite effective. The anesthesiologist had to give him intravenous sedation.

How could this wrong site surgery happened when the surgeon, the operating room(OR) nurses and other personnel all agree that the left inguinal hernia was was the the correct side? The OR schedule showed left inguinal hernia repair. The surgical consent was for left inguinal hernia repair. The surgeon marked the left side correctly. So it seemed.

Here is theoretically what could have happened.

The patient really did have right inguinal hernia but the surgeon wrote in the chart as left. If the mistake was not corrected here, a left inguinal hernia will be scheduled and the wrong side operation could happened. Any alert patient could have prevented this serious surgical error at the time of signing the consent. If he missed this opportunity, he would have another chance when the surgical site was being marked.

But our patient above was elderly and cognitively impaired and our busy and famous surgeon had performed four hernia repairs in one day, two left and two right.

How can we prevent this extremely rare but very serious mistake?

In my opinion, we should be able to prevent wrong site or side surgery 100 percent by following the following protocol strictly. This protocol will be created by the OR committee of a hospital.

1. Create a printed diagram of a full length human figure face-up on a standard sheet of paper . We will call this "Surgical Site Marking Sheet(SSMS)"

2. The surgeon will mark the surgical site on the SSMS, immediately after the patient was examined,right there in the office examination room, corresponding to the site written on the progress note in the medical chart.

3. The patient will be given a copy of the marked SSMS and instructed to bring it to the hospital on the day of surgery.

4. The surgeon will call the OR scheduler to schedule the operation AND fax the marked SSMS to the OR scheduler immediately.

5. No surgical procedure which requires a side or site will be put on the OR schedule without the marked SSMS.

6. The marked SSMS will be a permanent part of the medical record.

7. The procedure can not be started without the marked SSMS in the medical record. If the OR scheduler lost the Marked SSMS, obtain the copy the marked SSMS from the patient. If the patient forgets to bring it to the hospital, obtain a faxed copy from the surgeon's office.

8. The actual surgical site marking on the patient still can be done in the OR.

The above protocol is written in such a way that any patient will understand the process.

Currently, the SSMS protocol, with some variation from above, has been implemented in several hospitals in a Health System in Michigan. I can also say that I was involved extensively in it's implementation, of which the story will be told in a future post.

Wednesday, September 20, 2006

Plavix | Coronary Artery Stent | Bleeding Complications

Patients who have coronary artery stent are usually prescribed to take aspirin and Plavix. Most patients tolerate these two drugs quite well. The most common complication seen in my patients is bleeding.

I have two patients who had coronary stents and were put on these two drugs by the same cardiologist. The first patient developed massive lower gastro-intestinal bleeding requiring several units of blood transfusion. The aspirin and Plavix were stopped during this hospital ization. The bleeding stopped . The patient was discharged but was told by the cardiologist who put in the stent to continue to take Plavix and aspirin to prevent the stent from clotting.

The patient was confused. When she came to see me in my office, I told her that this was a dilemma. It's a tug-of-war between keeping the stent open and the risk of bleeding. After explaining to her the pros and cons, she decided to continue to take aspirin and Plavix.

For the next 6 to 8 months after the massive lower GI bleeding mentioned above, she had at least 4 or 5 episodes of lower GI bleedings requiring hospitalizations with blood transfusions once or twice. Of course each time the bleeding stopped after stopping aspirin and Plavix. Finally the patient told me that she was fed up with repeated bleeding. She decided to stop these two drugs permanently and accepting the risk of losing the patency of the stent. I agreed with her completely because she had made an informed decision.

After that decision, she did not have another bleeding episode for the next two years which is the present time. With her age of above 75 and the underlying colonic diverticulosis, she may still have lower GI bleeding in the future even without taking aspirin and Plavix. Her cardiac status has been stable.

The second patient had coronary stents and was prescribed aspirin and Plavix for a while without any bleeding complication.

One day he presented with upper abdominal pain in the office. Rectal exam showed black tarry stool and positive occult blood. A gastroscopy was done and and a mild bleeding of the gastric mucosa was found. He was told to stop aspirin and Plavix.

Not long after that he was back on aspirin and Plavix by the order of the cardiologist. Informed decision was made by him and his wife to continue these two drugs. So far so good; he does not have any more bleeding from the stomach. Of course he will be taking a medication in the family of Proton Pump Inhibitor(PPI) indefinitely.

In conclusion, informed decision by the patient is the best solution for the dilemmas described above, in my opinion.

Thursday, September 07, 2006

Laboratory Error | Reduce Medical Error

Laboratory errors performed by commercial laboratory service in in any medical office setting are very common. There are also many kinds of of mistakes. I am going to describe one common mistake.

Suppose the doctor order lab. tests as follow: Total Cholesterol(TC) and LDL-Cholesterol(LDL-c) but the lab. reports show the results of the Lipid Panel which consists of TC, LDL-c, Triglycerides(Trig.) and HDL-c. The ordering doctor should spot the error right away and call the lab. to correct the mistake by discarding Trig. and HDL-c.

Why should the lab. discard the 2 tests mentioned above? The answer is that the lab. can not bill the patient or the insurance company for any test without a doctor's order.

How can the mistakes described above happen? It can happen in 2 ways. First,it can be the clerical error of the medical office staff by marking the Lipid Panel slot on the lab. requisition sheet instead of marking just TC and LDL-c as ordered. The second scenario is that the medical office staff is correct but the lab technician carelessly does the Lipid Panel instead. The Trig. level must be done after a 12 hours fasting also.

In my office,we always keep a copy of the lab. requisition in a temporary file folder and file it with the actual test result when available. This copy will also serve to verify who makes the error.

This kind of error does no harm to patient but if not spotted early, it can cost money to patient and/or to the insurance company.

How can we prevent this kind of mistake from happening? In my office, we implement the following protocol:

  • Keep a copy of the lab. requisition and file it with the test results when available,usually the next day.
  • Staff puts the lab. result in my in-box immediately after it's comes in through the printer.
  • I check the lab. results as soon as feasible on the same day.
  • If there is any lab. error,I will instruct one of my staff to to call the lab to correct the mistake if it is feasible.
  • My office staff will log the error in the lab. error log book. The log will indicate the following: a)Our error or lab.service error, b)If it's our error,who committed the error,c) What type of error

Since the implementation of this policy many years ago, we accomplish the following

  • This kind of error was reduced to almost nil.
  • The performance of the lab. and my staff improved tremendously because there was no dispute as to who made the mistake.
  • Increase patient's satisfaction.
  • Help decrease one tiny area of of health care waste.

How can a patient spot this kind of error? Usually it's difficult for any patient to do that but you can do the following to reduce your out of pocket payment:

  • Check your medical bill as soon as you receive it.
  • If you suspect an error as mentioned above,ask your ordering doctor to explain the detail of the bill. Your ordering doctor or his designate should take time to answer your question.

Friday, September 01, 2006

The Sonoma Diet | Weight Loss | Real Story

Last week I posted on my other blog about The Sonoma Diet. It's about one of my patient who, upon my advice,bought and follow the diet plan in this book. He lost 40 lbs. in about 6 weeks. Detail about this real medical story can be read at
There are quite a few other patients that I recommend to read this book with little success. I saw one borrowing the book and reading it while waiting to be seen by me.
I could see that he did not enjoy that much. He promised me that he will finish it. Whether he will follow the diet plan or not,it remains to be seen. This patient weighs more than 350 lbs.

This is the first post after i switched to the new beta template. So far I really like it,being an amateur in blogging and no knowledge of HTML.