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Malpractice Data Analysis Offers Window into Surgical Error

Heather Comak, for HealthLeaders Media, July 13, 2010

"Physicians are by nature evidence-based, and a lot of the patient safety initiatives are not necessarily based on real evidence, which is why culturally they'll really push back," says Hanscom. "What we tried to do with the malpractice data ? because we analyze it as deeply as we do, it's rich in demonstrating where vulnerabilities are. It fulfills this yearning for evidence."

Technical skills
The malpractice data included in the report show that at academic medical centers, 27% of surgical cases have intraoperative complications and 9% have poor technique. At community hospitals, those figures are 29% and 17% respectively.

To strengthen technical skills, faculty at UPHS decided to use their simulation center to create a certification course around laparoscopic surgery technique. Unlike traditional programs that require something like this for residents and trainees, UPHS' program is for all staff, even those already trained and experienced in laparoscopic technique.

"That's not an easy thing to do. It takes strong clinical leadership, in addition to administrative leadership—the chairman of surgery and other clinical chiefs—to say, 'Yes, we believe we should do this because it's going to help us help our patients,' " says Sullivan.

It is this type of leadership that is necessary to create real change in the operating room (OR). The surgical culture is one of the most complex in healthcare, says Hanscom, and when leadership teams embrace programs such as the UPHS laparoscopic certification for all of their staff members, they set a standard.

To read more about the report and some ways that hospitals are increasing staff engagement and reducing the likelihood of error, see the August issue of Briefings on Patient Safety, a product of Patient Safety Monitor. To view the report in its entirety, click here.


Heather Comak is a Managing Editor at HCPro, Inc., where she is the editor of the monthly publication Briefings on Patient Safety, as well as patient safety-related books and audio conferences. She is also is the Assistant Director of the Association for Healthcare Accreditation Professionals. Contact Heather by e-mailing hcomak@hcpro.com.

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