Practice of Medicine
Reducing the Risk of Failure to Rescue
August 18, 2016
Understanding where risks occur in patient assessment is essential for successful outcomes
While there is much we can do to reduce the risk of complications after procedures in medicine, it is unlikely that our complication rate will ever be zero. Thus, it is important to strive for recognition of unanticipated outcomes as quickly as possible and to initiate rescue efforts and mitigate the effects of those complications for our patients.
Atul Gawande, a professor of surgery at Harvard Medical School, discussed this issue in a commencement address published for The New Yorker1 and pointed out that the major differences in morbidity rates among hospitals is not in the frequency of complication rates, but rather in the success the better institutions have in rescuing their patients when things do not go as planned after a procedure. We have noticed that the most common reason for not being able to defend a procedural complication lawsuit is due to a delay in, or inadequate, rescue efforts.
Two recent studies have looked at the issues around postoperative care and have revealed important lessons that hopefully can help us reduce harm to our patients. One study, published by the Bulletin of the American College of Surgeons2, is a retrospective review of a large claims database from a national professional liability company, which obviously has the limitation of identifying only events which have led to lawsuits. Nonetheless, the study identified the primary cause of delayed recognition was inadequate patient assessment, whether it was failure to order necessary tests, failure to consider the importance of those tests or other information, or over-reliance on negative tests when patients did not improve. Secondly, failure of communication among providers was the cause of many delays, not only regarding the patient’s current condition, but also regarding follow-up of incidental findings that fell through the cracks. These communications must not only include covering partners, but hospitalists, nurses, primary care providers, and family members as well. When postoperative patients call, office staff should be trained to not hesitate to contact the surgeon and to not make clinical decisions independently.
The second study appeared in the Annals of Surgery3 and was observational, following 50 surgical patients in the postoperative period, watching for process failures and other errors in their care. The study highlighted the number of “non-routine” events that occur in day-to-day practice that do not necessarily lead to patient harm, but that could be considered latent threats. There was an average of 6 of these non-routine events per patient, of which, a median of 4.5 were considered process failures. Most (85 percent) were considered preventable and more than half were due to communication failures or individual delays in acting.
One half of the process failures led to some form of patient harm, with many due to medication errors, management of lines and drains, and pain management modes of delivery. Inadequate patient assessment, as in the claims study, also had a higher likelihood of patient harm due to delays in rescue.
What can we learn from these studies? First, one should understand that a procedure on a patient is never without risk. We must accept the possibility of failure, and be prepared to admit it, recognize it, and take appropriate action. Secondly, due to the complexity of our medical system, failures of the processes we have put into place are very common, probably much more so than we are aware. We should be cognizant of the high-risk systems (such as management of lines and drains, and of pain medication) and take extra measures to ensure they are functioning smoothly. Thirdly, we should be aware that most of these malfunctions result from communication failures among providers. We should smooth the way for input from colleagues, nurses, patients, office staff, and others—and make use of that information as we continually assess our patients for progress in the postoperative period.
There is no substitute for a careful bedside assessment of the patient who is not doing well, and for careful and urgent consideration of further testing when indicated. In short, we should anticipate success, but should plan for failure, to maximize the likelihood of a successful operation for our patients.
1 http://www.newyorker.com/online/blogs/newsdesk/2012/06/atul-gawande-failure-and-rescue.html 2 http://bulletin.facs.org/2013/06/symptoms-of-normal-recovery/ 3 Annals of Surgery. 257(1):1-5, January 2013.
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