Much of what we have learned about priorities for improvement in health care has come from review of errors, complaints, and malpractice litigation. In 1991, Brennan et al1 reviewed patient care with bad outcomes in New York State and found that 3.7% of patients had suffered injuries related to medical care, of which nearly 28% were related to negligence. In that same study of over 30,000 patient records, Leape et al2 classified the adverse incidents by type (e.g., misdiagnoses, emergency room events, management errors). The Institute of Medicine (IOM) followed in 2000 with the report To Err Is Human: Building a Safer Health System,3 which elevated public concern about medical errors as a danger to patients and as a public health problem, and made clear that improvements in patient safety must be a priority of patient care. The IOM produced another report in 2001, Crossing the Quality Chasm: A New Health System for the 21st Century,4 that examined medical quality more broadly and described useful attributes of quality (safe, timely, effective, efficient, equitable, and patient-centered) that have been helpful in reconsidering the medical education curriculum5 and in involving medical staff in quality improvement efforts as part of staff credentialing and institutional oversight.
Current quality improvement efforts in many academic medical centers depend on the identification of cases with possible errors that are scrutinized at morbidity and mortality conferences6 or dissected in a multidisciplinary meeting using a root-cause analysis methodology. Decisions about medical licensure of a physician, as well as about appointment of a physician to a medical staff, often include review of the physician’s previous possible medical errors associated with malpractice claims.
While an understanding of errors and failures can help identify individuals and health systems with high risks for future problems,7 such an emphasis on what can go wrong ignores the performance of exemplary care that might also inform our understanding of both individuals’ and health systems’ excellence. An overemphasis on error can also create a culture of guilt, fear, and anxiety8 among health care providers involved in errors. For example, physicians have acknowledged that their fears about malpractice frequently lead to unnecessary tests.9 While medical education may emphasize evidence-based decision making—which incorporates the use of disease prevalence and test characteristics such as sensitivity, specificity, and likelihood ratios to limit unnecessary tests—our students are also influenced by the ubiquitous culture of fear of errors, and they learn that they will suffer far more criticism for missing a diagnosis because they did not order a test than because they ordered unnecessary tests.
In an effort to shift the current discourse about quality and safety in another, complementary direction, I present below a case (with identifying details changed) where everything went right, against great odds. I think there is much to learn from such cases—about teamwork, medical education, and creating a culture supportive of individual and team excellence through sharing and celebrating success. These are the cases that do not often get discussed at mortality and morbidity conferences and don’t end up on the front pages of the newspapers. But perhaps they should.
The man arrived by ambulance. I noticed that he was about my age and sweating, but I was struck by the look in his eyes as they locked onto mine. It was a look I had seen before—the look of galloping death that occurs moments before a patient loses consciousness as he recognizes that something profound is going wrong and he is powerless to stop it. The ambulance paramedics reported, “This 65-year-old man, visiting from Ohio, had a sudden onset of abdominal pain and back pain a few hours ago. Then he almost passed out. His vital signs are.…”
And then one of the nurses interrupted the report. “Blood pressure 60,” she said with alarm.
I looked back at the patient. Now his eyes were rolling back in his head. I immediately knew three things:
This man was about to die.
I thought I knew why.
It would take an extraordinary team effort and a lot of luck to save his life.
An intern and resident were working with me, and I directed the resident to put our portable ultrasound probe on the man’s abdomen while the intern and a nurse attempted to start an intravenous line. Within seconds the ultrasound revealed a terrifying image. The man’s aorta was greatly enlarged and calcified, confirming my initial impression that the cause of the man’s problem was a ruptured abdominal aortic aneurysm. By the time I saw the image, I could barely feel a pulse, and the man had become unconscious. I directed one of our technicians to assist the man’s breathing with a bag valve mask while we continued to place intravenous lines in the man’s arms, legs, and chest in the hope of providing blood and fluids to replace what had been lost from the aortic rupture.
“He’s about to arrest,” I told the team. Now a pharmacist arrived and asked if I wanted to order any medication.
“Sure, let’s give him some intravenous phenylephrine and see if we can raise the blood pressure,” I said, “and then we can start a drip of epinephrine or norepinephrine. I think he has a ruptured abdominal aortic aneurysm. Our only hope is to get him blood and fluids and have vascular surgery take him to the OR.”
The resident placed a subclavian line while the intern placed an arterial line, and we began transfusing blood into his veins. The vascular surgery resident appeared almost magically, having been called by the clerk. I told him what we suspected, and he nodded. I had expected some resistance, since we were making the diagnosis without the benefit of a CT scan and basing it upon our clinical judgment and interpretation of an ultrasound. It would have been easy for the vascular surgery resident to raise doubt and ask questions: Couldn’t this be a bleeding ulcer, or a ruptured appendicitis, or a pulmonary embolism, or a heart attack? These would all have been reasonable possibilities, but in the time it would have taken to investigate them, the man would have died. Fortunately, in this case the vascular surgery resident recognized the severity of the situation, appraised the information we presented to him, and agreed with our assessment. He called his attending and the operating room, and minutes later the man was on his way to the operating room for emergency surgery.
As I surveyed the room where the man had held center stage, there were discarded blood transfusion packages, sterile towels, IV tubing, masks, tape, and bandages strewn about the floor. But something miraculous had happened. Somehow we had pulled this man back from the abyss. Even more remarkable events would follow as our surgical and anesthesia teams would repair the ruptured aorta.
As I thought about this case, I realized that there were at least three lessons to be learned from our success.
The first lesson was the importance of clear communications. The emergency medicine team had almost immediately recognized both the seriousness of the problem and the most likely cause of it because the paramedics provided a succinct and accurate story that matched with the pattern of a ruptured abdominal aneurysm; the ultrasound findings quickly confirmed our impression. The immediate recognition of the problem led us to communicate the nature and severity of the problem to the surgery resident, who mobilized our surgical and anesthesia teams. In many cases, teams never get mobilized because the necessary information is not clearly conveyed or the pathological pattern is not recognized by those responsible for the critical decisions.
The second lesson was the critical role of trust between the emergency department team and the vascular surgery team. The surgery resident accepted the report of a clerk and rushed to the emergency department without hesitation. Any doubt or questioning of the diagnosis could have easily created a delay. Few would have criticized a more cautious approach, since there was risk in committing to surgery with limited information. Had the diagnosis been incorrect, the resident would have risked reprimand and the patient might have suffered unnecessary surgery and possible death. The ability to make a risky decision required a capable individual supported by a culture that valued a calculated risk to save a life over a self-protective approach to avoid blame. This is where institutional culture is critical. Health care organizations, with their rigid hierarchies, have not always supported a smooth decision-making process, particularly involving multiple teams and departments. In the case I have reported here, our decisions were fortunately correct; we made the right diagnosis, and the surgery resident and attending made the right decisions to trust our judgment. The vascular surgeons repaired the ruptured aorta through heroic and extraordinary efforts. The anesthesiologists provided the emergency management during the surgery. The postoperative intensive care team continued the management of the patient after the surgery. The patient survived.
The third lesson was the interdependence of individuals’ medical expertise and highly functioning teams. The outstanding surgical skills of our vascular surgeons were necessary for this man to survive, but they were not sufficient. The paramedics, the nurses, the emergency physicians, the clerk, the anesthesiologists, and the postoperative critical care team also passed this patient on to the next group as if they were carrying a fragile glass vase, and each carried that vase with skill and care, without breaking it.
There was an all-encompassing message as well: All members of our team were trying to do their very best. They were going all out, even taking risks, to save the patient.
The next day I visited the patient in the intensive care unit. I had no idea what I would find but expected him to be unconscious and on a ventilator, with various tubes connecting his body to machines, and surrounded by nurses and doctors. Instead, I found him awake sitting up in bed.
“Hi,” I said. “I am one of the doctors who took care of you downstairs in the emergency department. I don’t suppose you remember much about that?”
“No, I only remember that pain in my back, and the ambulance.”
“Well, I am glad to see you doing so well. It is really quite miraculous.”
“Yes, well I hope you will thank all of them. Please tell them how much I appreciate what they did for me.”
“Yes,” I nodded, “I will.” I looked over at his wife and she smiled pleasantly at me. I wondered if he really understood how close he had come, how fortunate he had been that everything went right for him. I wanted him to say something more profound, perhaps that he realized that he had been given a gift, that he would dedicate his life to some higher cause from now on in recognition of this gift.
But then I realized that we all have this same gift given to us every day. We take it for granted that we will wake up the next day. And this realization returns me to my original purpose for writing about this case. Just as we take each day for granted, we take our episodes of excellence in health care for granted. I am not sure how often they occur. I suspect they happen frequently in most major medical centers. Perhaps we could begin to identify those situations when we defied the odds through exemplary care and teamwork. We should learn from our successes so that we can replicate them. I decided to write e-mails to the chairman of surgery describing what had happened and complimenting the resident and faculty member responsible. That seems like a small thing, but when I did it, I realized how rare it was. I could remember having written only four such letters in my career. If we all wrote such a letter at least once a year, when we recognized extraordinary events and people who made a difference, we would be on our way to creating a culture of excellence and trust in our institutions. Culture is a term that we use often, and we invest it with many meanings, which can diminish its force. In its simplest form, culture is what we value and how we communicate it, so in health care it is about how we value life and understand illness, death, and suffering and how we communicate about it to our students and patients.
In this issue of Academic Medicine, Lavizzo-Mourey10 describes the Robert Wood Johnson Foundation initiative to create a culture of health. This notion of a culture of health combines wellness, education, community development, and public health with health care. Those involved in creating a culture of health would need to understand and support much more than curative health care services. A culture of health also includes a culture of safety and high-quality care, which leads to a culture of excellence in health care. The National Foundation for Health Care11 has emphasized the need to empower teams and reduce physicians’ egocentricity as part of a needed culture change. I believe the excellent function of teams was the key factor that led to the success in the case I described earlier.
Pololi et al12 in this issue of the journal also focus on culture—in this case, the culture of the medical school in which a faculty member works. They found that relationships/inclusion, values alignment, work–life integration, and institutional support contribute to faculty vitality. I would suggest that these are all components of institutional culture, and while we may not feel that we can change culture because it seems too big and impersonal, we can build relationships every day. By doing the little things like sending an e-mail that recognizes a colleague’s outstanding performance, we can begin to change our culture so that it demonstrates respect and trust. By recognizing, studying, and sharing our successes, we move beyond simply focusing on errors to improve care and can help each other become the best that we can be. In that way, we can create a culture of excellence.
David P. Sklar, MD