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Editor's Page: Desensitized to Death
Could the death of Joan Rivers be a wake-up call for surgical facilities?
Dan O'Connor
Publish Date: November 3, 2015   |  Tags:   Editors Page
OR Excellence

Interested in presenting at the 2016 OR Excellence Conference (orexcellence.com), which will take place at the beautiful Hyatt Regency Coconut Bay resort in Bonita Springs, Fla.? We are accepting proposals for keynote talks, general sessions, 3-hour pre-conference workshops and breakout sessions. Submit your presentation proposal to [email protected].

All submissions must be received by December 9, 2015. ORX speakers receive complimentary registration for the 3-day conference, a complimentary 2-night hotel stay and airfare reimbursement. Thank you in advance for your proposal and for making ORX surgery's can't-miss conference.

Our final speaker's final few PowerPoint slides at last month's OR Excellence Conference in San Antonio began and ended with a damning question:

What killed Joan Rivers?
We did.
Our industry did.
It was completely unnecessary.
It was preventable.
And can you believe we'll do it to another 439,999 people this year?

With that, you could hear a pin drop in the main ballroom at the San Antonio Marriott Rivercenter as anesthesiologist and patient safety advocate Kenneth Rothfield, MD, MBA, CPE, closed out ORX VII with a sensational talk, "Lessons Learned from the Death of Joan Rivers: Ensuring Patient Safety in Outpatient Surgery." After an uneasy moment of silence, the audience broke into well-deserved applause. It's hard to clap when you've just been indicted.

More than 400,000 U.S. citizens die from preventable medical errors each year. Imagine if we heard about 2 747 crashes every single day. That's what we're dealing with — well more than 1,000 preventable deaths a day. Yet we virtually never hear about it, until someone like Joan Rivers dies. We should be hearing about it. We should hear about every preventable medical error immediately after it happens.

Right now we don't, for a number of reasons. First, there's the way we talk about it. A surgeon clips the aorta or an anesthesiologist accidentally doubles a medication dose, or an unmonitored patient goes into respiratory failure in the PACU, and we call it a "complication." It's not disclosed publicly. There are patient privacy issues, after all.

Also, errors happen to individual patients, not groups of patients — unless actions by a provider affect a group of patients, like the Las Vegas GI doc who reused propofol vials. As Joseph Stalin put it, "One death is a tragedy. A million deaths is a statistic."

Dr. Rothfield Kenneth Rothfield, MD, MBA, CPE

That's why Dr. Rothfield used the story of Ms. Rivers to drive home the peg he would hang his talk on. "It changes the nature of the discussion when you talk about 1 person," says Dr. Rothfield, system vice president and chief medical officer at St. Vincent's Healthcare in Jacksonville, Fla. "My talk was 15 minutes of Joan Rivers and 45 minutes of patient safety. I'm still committed to the idea that we can do better."

Nobody likes the spotlight or the finger pointed at them, but the death of Ms. Rivers has drawn attention to the safety of outpatient surgery. Granted, publicity about preventable medical errors would hurt the healthcare industry in the short term. But in the long term, it could help us tremendously.

"Hopefully, the positive from this scrutiny will be a re-evaluation of policies and practices, and safety culture at surgical centers that result in improvements to patient safety," says Dr. Rothfield.

It's said that a death is meaningful if it imparts lessons others can learn from. Dr. Rothfield highlighted 3 lessons that can improve safety at your facility.

  • Assess and confront your culture. "If your people can't speak up," he says, "you're courting disaster."
  • Embrace checklists.
  • Be ready for the unexpected.

A lot of bad outcomes are scrubbed and sanitized as near-misses and therapeutic misadventures. "We accept a lot of things as the cost of doing business," says Dr. Rothfield. "Our culture is not very accountable." Focus on the first word in the term preventable medical errors. Our patients don't have to die. That should trump everything else.