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Lessons learned

by: LAWRENCE M. SHUER

All of us learn from our past experiences. Certainly, medicine is a discipline in which it is essential for us to examine the outcomes of particular treatments or surgical procedures, and use that information to improve our care of patients.

One of the most valuable lectures I remember from my own medical training was presented by Charles Drake, a pioneer of aneurysm surgery in neurosurgery, who discussed the surgical cases he wished he could do over. He addressed the complications that arose, of which some were preventable and others were not. His mission was to have others learn from his bad outcomes in the hope that they would avoid similar mistakes.

Similarly, here at Stanford we can learn valuable lessons from our care-review process. Through such forums as the service-level committees and hospital interdisciplinary committee, we should not only take away information that will prevent us from repeating our own past errors, but we should also learn from the experiences of our colleagues. With this in mind, I'd like to share some of the lessons we've learned through the care-review process over the past year or so.

One only has to read the newspaper to know that we have had some problems regarding sponges that were unaccounted for after surgery. We do have policies in place to deal with situations in which the final sponge count points to a missing sponge. The policies are aimed at making sure a patient does not leave the operating room with a sponge retained in the wound. The lesson to be learned here is that we must follow existing policies and strive to correctly interpret radiographs taken in the operating theatre so we don't overlook any missing sponges. The radiograph must include all portions of the patient's body in which the missing sponge could be located.

In a complex environment such as ours, it is crucial that we have good communication among the various physicians, nurses and other health-care practitioners. In no place is this more evident than in the operating room, where it is essential that the anesthesiologist and the surgeon constantly communicate what they plan to do. Likewise, any clinician involved in a given case must point out to all others involved any condition the patient has, so the appropriate pre-operative lab work can be obtained.

When consulting physicians make recommendations for medicating patients, the physician who writes the order is responsible for evaluating the safety and dosage of the medication.

The appropriateness of performing procedures on high-risk patients must be closely evaluated by the physician and the patient after reviewing all the risks, benefits and alternatives. The rationale behind the decision to perform or not perform the procedure must be documented in the medical record.

Radiologists and clinical lab personnel must notify referring physicians whenever a significant new abnormality is identified on a radiographic study or a lab test. To ensure that the referring physician receives the information promptly, it should be conveyed verbally as well as in writing. Similarly, it's the physician's obligation to obtain results on all tests he/she orders.

Surgeons must review all relevant pre-operative information before performing a surgical procedure. This information includes, but is not limited to, the pre-operative history and physical, previous surgical reports, and diagnostic laboratory and radiology tests. It is also strongly advised to have the radiology films in the operating room for reference, particularly when understanding the patient's particular anatomy is essential for the proper performance of a given procedure.

Orders for procedural moderate sedation should be written with the use of short-acting drugs that can be titrated up as needed. Larger single doses or the use of long-acting drugs can lead to oversedation. These are just a few of the issues that have been discussed recently in the care-review committee. I hope we can all take these lessons to heart and incorporate them into our practice.

If you have suggestions, questions or concerns, please call me at (650) 723-5371 or write: lshuer@stanford.edu