More evidence of the urgent need for “checklists” to protect patient safety in complex medical treatments comes with a long article in the New York Times about terrible injuries from malpractice episodes during radiation therapy. Yet readers have to dive deep into the article to find this key point.
Scott Jerome-Parks suffered terrible radiation burns to his neck, and lingered for two years in agony before dying, because he received a seven-fold overdose in the radiation that was supposed to treat his tongue cancer, on three separate occasions. Why did it happen? The hospital, St. Vincent’s in New York, blamed a confluence of tragic coincidences. But I reached a different conclusion, as I wrote in a blog post to the Times’ “Well” blog:
Deep in this tragic article is the following paragraph that exposes the reforms that are needed before medical care can become safe for all patients:
“It was customary – though not mandatory – that the physicist would run a test before the first treatment to make sure that the computer had been programmed correctly. Yet that was not done until after the third overdose.”
So there you have it. If the physicist had been required to run the test — better yet, if the equipment had been set so that it wouldn’t work until the final test had been run — Scott Jerome-Parks would not have suffered the hideous injuries so eloquently described in the article.
Medicine needs to adopt standard and mandatory – not merely “customary” — checklist routines to ensure the safety of patients. This is the thesis of Atul Gawande’s new book, “The Checklist Manifesto,” and I have a chapter on how patients can enforce checklist protocols before surgery in my own book, “The Life You Save: Nine Steps to Finding the Best Medical Care — and Avoiding the Worst.”
Many medical commenters on the New York Times “Well” blog defensively say, “We’re only human,” to excuse these kinds of errors. Yes! That’s exactly the point of the checklist. It recognizes that we’re all only human and that when we are deploying potentially deadly treatments, a final check and double-check is needed, every time, before pressing the button.
The Times also found that the manufacturer of the software that ran the linear accelerator, which delivered the radiation, did not have in place until after the injury a simple “fail-safe” mechanism to prevent the kind of error that occurred.
The entire article by the brilliant reporter, Walt Bogdanich, is worth reading. Here is the Times’ own summary of the article:
The Times found that while this new technology allows doctors to more accurately attack tumors and reduce certain mistakes, its complexity has created new avenues for error – through software flaws, faulty programming, poor safety procedures or inadequate staffing and training. When those errors occur, they can be crippling.
I also recommend that readers interested in patient safety issues go through some of the NYT “Well” blog posts on this article.