Mistake-Proofing in Hospitals: The Case of the Wrong Film

A disturbing account of a medical error appeared recently in a story in the Modesto Bee newspaper in California. It highlights the need for mistake-proofing measures.

            A surgeon performing coronary bypass surgery on a woman discovered midway through the operation that he was using angiogram films from a different patient. An angiogram film serves as a roadmap for a surgeon in deciding where to bypass clogged arteries.

            The surgeon, Dr. Lit Fung, claims that the woman’s heart was very similar to the other patient’s, and he was able to finish the surgery successfully.

            However, the woman, Sandy Baumgartner, sued. She claims that her condition was no better after surgery than before, with some symptoms worse. And she contends that a second doctor she consulted after the surgery discovered that one bypass had missed the worst blockage, requiring follow-up treatment involving a stent and an angioplasty.

            The hospital involved, Memorial Medical Center, agreed to a settlement, but the suit against the surgeon is still pending.

            I won’t attempt to pass judgment on the merits of the suit. But the broader question is, how did the error occur and how can future errors be prevented? According to the story,

            At Memorial, the pictures are put on discs in the cath lab and must be hand-delivered to the operating room. The patient's name appears on the films when they're opened on the computer.

According to Baumgartner, a hospital representative told her a catheterization lab employee had burned two discs of the other patient's angiogram and mistakenly put her name on the cover of one disc.

Fung wrote on the medical record of Baumgartner's surgery that the films of 'a different patient had been loaded onto the computer.'

Gary Baumgartner has run his wife's angiogram films on his home computer and said her name is on the film. He believes the other patient's name also would have appeared and is outraged that the surgeon and operating personnel did not notice that during surgery.

            What type of mistake-proofing could prevent this from happening? The story, by Ken Carlson, offers one idea:

            Another Modesto heart specialist said the computer system at Memorial does not have a database link between the cath lab and operating rooms, so employees have to handle the discs.

In comparison, surgeons at Doctors Medical Center can access angiogram films from computers in the operating room. The surgeons click on the patient's name to call up the films.

A surgeon would have to click on the wrong name to make a mistake.

            Does anyone really need to be reminded of how critical it is to avoid errors in hospitals? Apparently so.


1 comment:

Ralph Bernstein said...

7/14/2007 2:41:49 AM
Re: Mistake-Proofing in Hospitals: The Case of the Wrong Film
By: thopper

It's an interesting case, from a process improvement perspective. Creating a database link between the lab and the operating rooms would clearly help. As would using bar codes on patient wrist bands to positively match them to their records. However both solutions would seem to require a fairly substantial investment in time and money to implement.

A good rule of thumb is that Poka-yokes are, at best, easy to implement and very visual. In that spirit, I've been trying to think of ways to avoid the error in this article with minimal investment in time and money. Not knowing the hospital systems, here are a few ideas:

1) Have the database that burns the films to CD also print CD labels, rather than rely on the operator to write the patient's name.
2) It sounds as though the operators are batching CDs, so that they label two or more at the same time. Change the process of burning and labeling CDs so that the operators handle only a single set of films and CD at a time, essentially going to single-piece flow.

I would be interested in what other, easy-to-implement, ideas readers have (recognizing that none of us have studied this hospital's process, and so are dealing in hypothetical situations).