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Medical mishaps call for change in health care culture

Publish Date: 1/30/2013

Leslie Knudson

Managing Editor, Connections 

A recently published study conducted by researchers at Johns Hopkins University School of Medicine has shed new light on the continued prevalence of preventable errors in United States health care. According to the study; published in Surgery, surgical “never events”—labeled as such because they should never occur and include retained foreign bodies, wrong procedures, and wrong-site and wrong-patient surgeries—happen more than 4,000 times a year in the United States.1 In addition, the study estimates that a foreign object is left inside a patient 39 times per week and a wrong surgery or wrong site surgery is performed 20 times per week.1 

Using data from the National Practitioner Data Bank to identify malpractice judgments and out-of-court settlements related to such events, the study is the first of its kind to help quantify patient safety problems on a national scale. Numerous studies have revealed the lag in progress in specific patient safety areas in the past decade—according to the Centers for Disease Control and Prevention, more than 150,000 patients nationwide have been victims of unsafe injection practices since 2001,2 and the U.S. Food and Drug Administration has received more than 95,000 reports of medication errors since 2000.3 The alarmingly high rate of medical mistakes calls for greater accountability and a higher standard of patient safety and quality of care.

A systems approach

“Surgical never events continue to be a problem, despite all the advances in science and technology,” said Marty Makary, MD, MPH, FACS, lead author of the Surgery study and an associate professor of surgery at Johns Hopkins. “The reason is that culture affects these types of mistakes. The science of safety has matured to the point where we recognize it’s the workplace culture; it’s the safety culture; it’s the environment.” Makary has pointed to the “corporatization” of health care as a culprit of medical errors, creating a culture that rewards doctors and facilities based on the number of patients and procedures rather than patient outcomes.

Although the age-old culture of medicine is slowly shifting from a fee-for-service to pay-for-performance model, workplace culture is at the root of the needed change. “Science is not going to solve the problem of patient safety,” said Makary. “Technology is not going to solve it. We need smarter hospital systems in the context of a good working environment.” Developing better hospitals systems is a complex, multifaceted task that requires cultural, management, and practice changes, including:

  • Speaking up
    “Speaking Up” is a new organizational culture that endorses rather than penalizes medical personnel for voicing their safety concerns. “Many institutions are now working towards creating a culture of speaking up where nurses, technicians, and others in the operating room are encouraged to voice their safety concerns and there’s a strong institutional backing from the highest levels of leadership to ensure that people voicing their concern
  • Use of surgical checklists
    Surgical checklists, such as the AORN surgical checklist and the World Health Organization surgical checklist, are designed to prevent wrong procedures and wrong-site and wrong-patient surgeries by verifying critical information as part of an OR team dialogue immediately before surgery. “We found that checklists are associated with an improved patient safety culture in the operating room; the results are more operating room personnel feeling comfortable speaking up,” said Makary.
  • Compliance with evidence-based practices
    Implementing evidence-based recommended practices, such as those provided by AORN, helps to ensure optimal patient safety outcomes.
  • Closing the divide between management and front line providers
    “We’re seeing a dichotomy in U.S. hospitals where some hospitals have management that is in touch with the front line providers and some hospitals where management is out of touch or detached,” said Makary. “This is a dangerous trend because when management is detached from the front lines in any industry, quality goes down and mistakes go up.” Better reporting systems and improved transparency can close the gap and serve as an internal management tool to encourage staff members to adhere to higher standards

The transparency movement

Under the Affordable Care Act (ACA), hospital delivery and payment methods are changing as the health care system moves towards outcome- and performance-based models. Additional changes brought on by the ACA, such as greater individual financial contributions toward insurance premiums, deductibles, and copayments and the implementation of state health insurance exchanges, are creating an arena of competition and comparison shopping for health care. The competitive environment is further enhanced by increased access to publicly reported health care performance information, a staple part of health care reform.

As information is becoming increasingly public and patients are beginning to be viewed as consumers, hospitals are becoming more attentive to the patient experience. “We’re seeing a race to the top with the new publicly reported metrics,” said Makary. “Hospitals are increasingly aware that their performance is public information and that the general public believes that they have a right to know about the quality of their hospital. There’s a transparency movement in health care to make bedside care more honest.”

According to a PricewaterhouseCoopers report, 72 percent of consumers ranked provider reputation and personal experience as the top drivers of provider choice.4 Several online resources are available that offer comparison and feedback information related to doctors, hospitals, and the patient experience, such as the Center for Medicare & Medicaid Services’ Physician Compare and Hospital Compare websites, Consumer Reports, Vitals.com, and ZocDoc. “We have patient satisfaction scores now measured by hospitals and publicly available through many different avenues for patients to describe the quality of their experience,” said Makary. “With patient satisfaction scores increasingly being weighted for public scoring of hospitals and ranking systems, we’re seeing hospitals pay a lot of attention to the patient experience.”


In this new age of the informed, empowered patient, patients are not only looking to compare doctors and hospitals, but also to find information regarding treatment options, complication rates, and medical mistakes. Industry proponents support expanded availability of information on safety, quality, and cost, and the inclusion of surgical never events as a quality metric in health care reporting requirements. Along with the call for greater availability of public performance information, supporters of the transparency movement have also expressed the need for standardized reporting to allow for apples-to-apples comparisons and national standards of accountability. Ultimately, the responsibility lies with patients, as consumers, to demand greater transparency and help shift the health care culture towards one with higher standards of quality and patient safety.


1. Mehtsun WT, Ibrahim AM, Diener-West M, Pronovost PJ, Makary MA. Surgical never events in the United States. Surgery.
Accessed January 11, 2013.
2. Digital press kit: the impact of unsafe injection practices in U.S. healthcare settings. The Centers for Disease Control and Prevention.
Accessed January 11, 2013.
3. FDA 101: medication errors. U.S. Food and Drug Administration. 
Accessed January 11, 2013.
4. Customer experience in healthcare: the moment of truth. PricewaterhouseCoopers.
Accessed January 11, 2013. 

Congress General Session Speaker: Marty Makary, MD, MPH, FACS

Marty Makary is the New York Times bestselling author of “Unaccountable,” a new book on how teamwork and transparency can rescue American health care, designated a 2012 Library Journal Book of the Year. Makary has written for The Wall Street Journal and Newsweek, is a medical commentator for CNN and Fox News, and speaks nationally on the future of health care in America. A pancreatic surgeon at Johns Hopkins and an associate professor of health policy and management, Makary was the lead author of the original publications on OR checklists. He served on the WHO checklist committee and chaired the WHO workgroup on measuring surgical quality worldwide.

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