Beyond Policies and Procedures

Maureen Larkin, for HealthLeaders Media, September 25, 2008

During the investigation that follows a sentinel event, hospital officials usually discover that somewhere along the line, a key safety step was overlooked or omitted, leading to the error. That step may be verifying a patient's medications, or stopping for a "time out" before the first cut is made. Without these, and others, the chances for error increase significantly. But what happens when a medical error is made, and all protocols were followed?

That's what apparently happened last week at Miriam Hospital, part of the Providence, RI-based Lifespan health system. On Friday, a surgeon at the hospital performed a knee replacement on the wrong side of a patient's body, despite following the necessary safety steps and procedures.

President and CEO Kathleen Hittner, MD, told The Providence Journal that the surgical team correctly went through all of the hospital's required safety checks before surgery, including placing a mark on the knee that required operation. Six members of the surgical team verified the surgery site before the procedure began, Hittner told the newspaper.

Is that possible? Six different medically trained individuals didn't notice that it was the right knee that was draped and prepped for surgery, instead of the left? Six people didn't notice that the skin that was about to be cut wasn't marked with a marker, as was standard procedure? It seems hard to believe, but according to hospital officials, that's the case.

If indeed the surgical team took all of the necessary precautions before surgery, it's a good indicator that policies and procedures alone won't prevent errors from occurring. In that same article from The Providence Journal, The Joint Commission's chief patient safety officer acknowledges that wrong-site surgery "continues at an alarming rate." The Joint Commission has required hospitals to verify patient identity, confirm the surgery being performed, mark the surgery site, and take a time-out before a procedure since 2004, but these rules haven't changed the rate of surgical errors reported each month.

So is medicine doomed to fail at error prevention? It depends. If healthcare keeps relying on policies and procedures as the only safeguard against errors, then the answer is probably. That's why healthcare needs to continue looking for new approaches. Last month, I wrote about a session I attended at the Quality Colloquium at Harvard University that compared healthcare to aviation. In that session, Jim Bouey, former director of safety and airworthiness for Boeing Commercial airplanes, said if we want to overcome the human tendency to err, we must learn the shortcuts the human brain creates and find ways to get around them. That's why on an airplane, for example, all cockpit instruments have standard shapes and meanings.

I wasn't there when six clinicians agreed to operate on the wrong knee, but something tells me that the error that occurred at Miriam Hospital last week was the result of too many brains taking shortcuts. To prevent wrong site surgeries and other sentinel events from occurring, healthcare must go beyond policies and procedures and examine what it is about humans that causes us to err.

Maureen Larkin is quality editor with HealthLeaders magazine. She can be reached at

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