Bob Wachter Reflects on Hospital Safety

Over the past two weeks, Bob Wachter, Associate Chairman of the Department of Medicine at the University of California, San Francisco, has published two provocative posts on hospital errors and patient safety on The Health Care Blog (THCB) (

The first post, which appeared on November 22, focuses on  a breakthrough article in the New England Journal of Medicine, a candid  report of a case in which Dr. David Ring, a prominent Harvard hand specialist at the Massachusetts General Hospital (MGH),  performed the wrong operation on a 65-year-old woman. She needed a trigger finger release, but received a carpal tunnel release, an entirely different operation. In the November 11 issue of the NEJM, Ring described his own error, with safety expert Gregg Meyer providing commentary.   

“This was a breakthrough for the Journal,” Wachter notes, “the first time in its storied 86-year history that the Case Records of the MGH published such a report. But it was not the first opportunity the NEJM had to publish such a piece… that occurred a decade earlier. The story of the path from then to now reflects the evolution of the patient safety movement. It’s a story I know well since it involved one of the lowest points in my professional life”

Wachter  then goes on to recount how, back in 2000, he and a group of colleagues went to the NEJM and proposed producing a series of case-based articles about medical errors. “The Journal replied swiftly and positively,” Wachter recalls, “going so far as to permit us to recruit authors by telling them that the series had ‘tentatively been accepted for publication in the NEJM pending peer review.’ Before giving it a final green light, though, they asked to see a couple of examples of cases and commentaries.”

But when Wachter sent the manuscripts to the NEJM,  the editor, Dr. Jeff Drazen, rejected them.  Wachterr remembers his explanation: “’We love the concept,’  Drazen said, ‘but we need the articles to focus on things that doctors can do to fix the problem of medical mistakes.’ Referring specifically to the one article, which had identified 17 distinct errors, Drazen continued. ‘It’s just too messy, there are simply too many problems.’”

Unfortunately, that is the nature of medical errors–they’re “just too messy.” Rarely is one person responsible; rarely could one doctor “fix” the problem. Wachter points to the recent mix-up at Mass General, listing the many factors which conspired to contribute to a “breathtaking error”:

– The patient spoke only Spanish, so that the surgeon, who spoke the language, ended up serving as the interpreter, distracting him from his primary task.

–   None of the other members of the OR crew spoke Spanish, so they mistook the surgeon's pre-op conversation with the patient for a Time Out. The result was that no formal Time Out was performed.

–   A nurse, rather than the operating surgeon, marked the site pre-operatively.

–   The nurse’s pre-operative site marking was washed away when the site was prepped and cleaned.

–  The OR’s slick new computer screens blocked the nurses’ view of the patient.

–   It was “one of those days” and everyone was stressed: the OR was running well behind schedule, nurses were being pulled off their previously assigned cases and sent to staff others (including the nurse who performed the pre-op site marking), and Dr. Ring had just completed another case on a very anxious patient. Talking her down just added to his level of distraction.

It wasn’t that one person made a mistake; the “system” wasn’t working to support the hospital workers and protect them against mistakes. As a matter of policy, the hospital should have provided an interpreter for the patient; the surgeon should not have been cast in that role. Meanwhile, procedural rules should have insisted the surgeon himself mark the site, pre-op. If the team had held the normal “time out” presumably someone would have noted that the pre-op site marking had washed away. The new computers should never have been placed so that they would block the nurses’ view of a patient.  Finally, on a hectic day, it becomes all the more important that everyone slow down and hold a “time out” before proceeding with surgery. ‘

“If we’re going to tackle the problem of medical mistakes, we need to begin thinking in terms of ‘systems,’” Wachter tried to tell the editor of the NEJM. (He failed the convince him, but the series of articles about medical mistakes was later published in the Annals of Internal Medicine.)

All of this happened ten years ago.

What is discouraging, Wachter observes is that, since then, hospitals have made relatively little progress in combating errors.

In his second, November 22 THCB post, Wachter points to “a depressing study published  in the  November 25 issue of the New England Journal of Medicine, looking at a stratified random sample of ten North  Carolina hospitals, and finding no evidence of improved safety over a five-year period, from 2002-2007.  Of course, this is a small group of hospitals in one state, but  North Carolina has a reputation for emphasizing patient safety, and these hospitals volunteered for the study, which suggests that they are proud of their efforts to reduce errors.

Wachter acknowledges the limits of the study (for example, the hospitals may have made more progress in the past three years), but nonetheless concludes:

“we’re coming to understand that to make a real, enduring difference in safety, we have to transform the culture of our healthcare world – to get providers to develop new ways of talking to each other and new instincts when they spot errors and unsafe conditions. They, and healthcare leaders, need to instinctively think “system” when they see an adverse event, and embrace openness over secrecy, even when that’s hard to do. Organizations need to learn the right mix of sharing stories and sharing data. They need to embrace evidence-based improvement practices, while being skeptical of ones that seem like good ideas but haven’t been fully tested. And policymakers and payers need to create an environment that promotes all of this work – policies that don’t tolerate the status quo but steer clear of overly burdensome regulations that strangle innovation and enthusiasm . . . . “

Wachter adds: “I worry that a harmful orthodoxy has crept into the safety field. We need to figure out ways to ensure that we do the things that we know work, like checklists to prevent central in infections and surgical errors, fall reduction programs and teamwork training.. We need to develop new models for those areas that haven’t worked as well as we’d hoped, like widespread incident reporting and CPOE. We must do the courageous and nuanced work of blending our “no blame” model with accountability when caregivers don’t clean their hands or perform a pre-op time out. And we must allocate the resources, at the institutional and federal level, to do these things and study them to be sure they’re working.”

I would add only that hospitals need to begin investing the dollars that they have been spending on construction and expansion on patient safety.  In addition,  if more medical journals published candid case histories of medical mistakes like the one that just appeared in the NEJM, hospital administrators, physicians and patients might become more aware of how important it is that hospitals follow procedures designed to protect patients–especially in some of our busiest academic medical centers.

5 thoughts on “Bob Wachter Reflects on Hospital Safety

  1. The example of the North Carolina hospitals reminded me of a conversation I had with a colleague about hospital safety, checklists, and systems errors. She is a former NC OR nurse. Her opinion was we were already doing what needed to be done to prevent systems errors, that no new changes were needed. I could not get her to see that these problems DO exist, that systems are routinely violated, and errors continue to happen.
    Scary. And my friend is a great nurse.
    At the CC where I teach, we use Simulation as a training tool for our nursing students. We make the simulations as real as possible, and one of the goals of simulation is for the students to remember basics like checking armbands and confirming patient identification.
    By the time they get to the senior level, they get a lot better about remembering these things because we have pounded it into them. But without an emphasis on good systems in the workplace, I fear future nurses will slip into bad habits as they try to cope with the increasingly heavy workload of patient care.

  2. In addition to the human suffering that medical errors cause they are a significant cause of increased cost in health care. Medical errors cost at least $70 billion a year, and a study led by Paul O’Neill, the former Bush secretary of treasury, suggested that errors and related mistakes actually cost more than $500 billion a year.
    Those are expenses that we can readily do without. The costs of correction, mostly in the form of low tech efforts at correctly checking and double checking compliance with proven standards of care — most of which are in turn low tech, are tiny compared with the reward both in preventing suffering and death by patients and in saving large amounts of money. The impediment, as Panacea notes, is primarily the position by health professionals that they are already doing what needs to be done and see no need to impose additional safeguards.

  3. Panacea, Pat S.
    Yes, I’m afraid your friend’s attitude is not uncommon. Health care professionals just don’t like to admit –even to themselves–that they are doing things that can harm patients.
    Unfortunately, trying to force people to improve safety doesn’t work very well. They have to be personally committed to the idea that they CAN transform their workplace into a place where patients will be safer.
    Don Berwick (co-founded of the Insittute for Healthcare Improvement and now head of Medicare) is very good at inspiring people to believe that We Can Do Better.
    We need more hospital CEOs like Berwick–people capable of inspiring passion. Unfortuately, too many hospital CEOs think that “doing better” means growing revenues rather than improving the quality of care. Inspiration should begin at the top, but in this case, nurses and doctors may need to join together, form committees that focus on safety, and inspire their colleagues. . .
    Under the Affordable Care Act, hospital infection rates will be published –that may wake up some hospitals when they see where they rank on the list.
    In general “counting”–how many medication mix-ups do we have each year?
    how many falls? how many patients with bedsores? how many post-surgical infections? etc etc. can help, especially if hospitals compare themsleves to the average rate– and to a benchmark based on the safest 5 percent of all hospials.
    But, as Naomi’s Nov 17 post points out, we don’t yet have really good information on quality of care at hospitals. Under the ACA, this should change.
    Pat S.–
    Yes, improving hospital safety seems the most obvious way to reduce spednding while lifting quality.
    But heatlh care professionals hate to admit that they, or their hospital, has been hurting patients.
    About a year ago, I was at a salon dinner with a group of hospital exectuives, and I suggested that anyone going into the hospital really needs to have a friend or relative serving as a patient advocate–someone who can ask questions (“that doesn’t look like the medication she took last night?”) and watch out for risky behavior (“I know you’re busy, but could you wash your hands before changing her dressing?”)
    I emphasized that a patient needs an advocate even at the most prestigious hospitals.
    At that point, the CEO of a major academic medical center in NYC practically lunged across the table at me, red-faced, veins popping in his forehead: “Patients do NOT NEED an advocate at my hospital!” he shouted. “We don’t make mistakes.”
    I was stunned.
    The level of denial is clearly very high –perhaps particularly at the very top of institutions that care more about their public reputation than they do about what’s actually happening in the OR.
    See my reply to Panacea.
    We really need to clone people like Berwick and Wachter and put them in every hospital in the U.S.
    Alternatively, physicians and nurses can band together to create a safer workplace, calling on the administration to enforce
    new rules and procedures (even if this annoys some “rainmaker” physicians.)
    Physicians and nurses interested in becoming part of the solution shoudl take a look at the IHI website (
    and consider attendign one of their conferences. Alternatively, just reading what’s on the website will give you ideas.
    As Berwick says, most professionals Want to do a better job, but too often, the systems in their workplace get in the way . . .Those systems need to be changed.

  4. Maggie:
    It’s not enough to say that hospital administrations and Boards need to think differently and admit the truth. The incentives that induce them to think as they do are perverse and act counter to the needs of patient safety. As long as the compensation and bonuses of hospital CEO’s are tied to their share prices in for-profit hospitals, and to their revenues in non-profit hospitals, they will focus more on their “public reputation” (which operationalizes as $$$) and deny the truth (which operationalizes as “risk”). What hospitals have ever posted their mortality and morbidity outcomes on their web sites?
    On the other hand, in organizations like the VA, where most doctors are employees and the administration can focus on their mission–safe, effective and efficient patient care–the focus is always on patient safety, there is public accountability for their outcomes, there is an Ethics Department they can go to for advice, and their quality measures are better than the rest of the US healthcare system.

  5. A. Carroll–
    All that you say is true.
    As Berwick points out, hospitals need to learn to think of themselves as cost centers, not revenue centers.
    In other words, their goal should be to lower their operating costs by becoming more efficient– which also means safer– since more efficient care is more coordinated care.
    Th Affordable Care Act attmempts to put some financial pressure on them by trimming Medicare’si Increases in payments to hospitals by 1% a year.
    MedPAC reserach shows that when under some financial pressure, hospitals do manage to become more efficient–and in fact are able to turn a profit on Medicare’s payments.
    If this 1% a year cut were combined with a major push for safety–combined with
    publishing infection rates, info on medical errors, etc– we might well get hospital CEOs to begin focusing on the quality of care.
    I also would love ot see more states adopt the Maryland solution to paying hospitals. AS you no doubt know, in Maryland, all insurers, public and private (including Medicare) pay all hospitals the same rates for the same services (after adjusting for differences in the cost of labor in different parts of the state, the percent of very sick and poor patients that the hospital sees, whether it is a teaching hospital with extra costs, etc.
    In other states, “brand-name” hospitals force private insurers to pay them more for even very simple services: how much a hospital is paid depends on market clout.
    Thus, many marquee hospitals are overpaid– and they tend to then waste the money, building new wings that are not needed. And, of course, once they build the beds, tehy fill them.