From MIMEPS to the Surgery Card

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From MIMEPS to the Surgery Card

• Scott E Regenbogen MD MPH
• Department of Surgery
• Massachusetts General Hospital
• Department of Health Policy and Management
• Harvard School of Public Health

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Surgical Adverse Events

• 66 adverse events related to surgery
• Utah/Colorado 15,000 admissions, 28 hospitals

Gawande, Surgery 199912666
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To Surgical Safety Stepwise

• Identify causes and characteristics of safety
  failures
• Develop novel strategies
• Evaluate baseline performance
• Adopt and test interventions

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JCAHO Sentinel Events
66
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Communication in Surgery

• MIMEPS Surgery (Rogers, Surgery 2006)
• 24 involved communication breakdowns
• Interview Study (Gawande, Surgery 2003)
• 43 involved communication breakdowns

Rogers, Surgery 200614025 Gawande, Surgery
2003133,614
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Communication in Surgery

• Breakdowns are common in the OR
• 30 of all transmissions
• 90 of operations (mean 9 per case)
• How can we target safety interventions?

Lingard, Qual Saf Hlth Care 200413330 Christian,
Surgery 2006139159-73
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To Surgical Safety Stepwise

• Identify causes and characteristics of safety
  failures
• Develop novel strategies
• Evaluate baseline performance
• Adopt and test interventions

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Data Source

• Malpractice Insurers Medical Error Prevention
  Study (MIMEPS)

444 claims from 4 liability insurers (21,000
physicians, 46 hospitals)
258 cases with injury due to error
Secondary Review (81 discrete breakdowns)
60 with communication errors
Rogers, Surgery 200614025
Greenberg, Regenbogen, et al. J Am Coll Surg
2007204533
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Specific Aims

• Identify key contributing factors to preventable
  injuries
• Identify key players in breakdowns
• Design and test safety interventions

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Description of Breakdowns
(MIMEPS Overall) Preop 25 Intraop
75 Postop 35
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Description of Breakdowns
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Most Common Agents
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Systems and Human Factors
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The Stereotypic Breakdown

• Single, verbal breakdown in elective case
• One transmitter and one receiver
• Involves surgical attending, most commonly
• With another surgical attending
• With a surgical resident

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To Surgical Safety Stepwise

• Identify causes and characteristics of safety
  failures
• Develop novel strategies
• Evaluate baseline performance
• Adopt and test interventions

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Surgical Safety Collaborative

• CRICO-sponsored
• Harvard Chiefs of Surgery
• Quarterly meetings
• Communications Working Group
• Brainstorming interventions

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Working Group Proposals

• Triggers for prompt Attending contact
• Attending coverage and handoffs
• Daily patient visits by Attendings
• (or appropriate alternative)

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Potential Impact
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To Surgical Safety Stepwise

• Identify causes and characteristics of safety
  failures
• Develop novel strategies
• Evaluate baseline performance
• Adopt and test interventions

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Communication of Trigger Events
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Attending Contact by Type of Event
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To Surgical Safety Stepwise

• Identify causes and characteristics of safety
  failures
• Develop novel strategies
• Evaluate baseline performance
• Adopt and test interventions

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Results Overall
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Results in Hospital 1
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Conclusions

• Malpractice claims data
• Identify points of emphasis
• Target innovations and interventions
• Key considerations
• Scope of inquiry
• Generalizability
• Next steps

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Acknowledgements

• Collaborators
• Andrew Elbardissi
• Caprice Greenberg
• David Studdert
• Atul Gawande
• CRICO Surgical Safety Collaborative
• MGH A. Warshaw, D. Berger, C. Wright
• BWH M. Zinner, M. OLeary
• Childrens A. Retik, D. Roberson, B. Cilento
• BIDMC J. Fischer, S. Karp, D. Moorman