Sunday, 9 December 2012

Blame it on human error

Blame it on 'Human Error', after all everybody knows that to Err is Human

Can you see what is happening in the pictures above? Of course you can. They are two infusion pumps with two different types of numerical key pads.

Can you now see how easy it would be for a tired nurse or an even more tired doctor when they are really busy at 3 am to confuse between the keypads and make a mistake?

Would that be counted as human error? Probably yes. But is that human error? Certainly not. This situation would be without doubt a systems error at two levels. Firstly for the manufacturers not standardising numerical keypads. Secondly for the buyer/healthcare facility for buying and using pumps with two different key pads in their premises. By doing so we have designed our system to fail, we have designed for the humans in our systems to fail. Avoiding that is what human factors is all about.

Let us assume that a clinician made an error in a facility that both these styles of numerical keypads in use in say adjacent beds/wards/floors. The investigation would only show that the clinician made a human error in pressing the wrong numbers in that particular key pad. That would be a fact. Would that be the whole truth? No. A standard investigation would not show that the error was triggered by the system by having those two types of keypads in adjacent areas. The investigation would probably end by stating that individual clinicians are responsible for their actions. Then the clinician would be sanctioned against, sometimes that is insultingly yet euphemistically called providing enhanced support and training for the concerned clinician.

The reason called 'human error' becomes a convenient parking lot for system errors that mostly go unrecognised due to poor management and poor investigators who have not much clue about human factors. Human error is easy, its tangible, you have someone clearly responsible and someone who has failed in their responsibility. Every one understands human error. System error recognition is very complex, its often fuzzy, once recognised there is no one to 'blame', to be held responsible. After all that, resolving system errors takes patience, time, energy and technical skills which many would pretend to have. It is frightening to imagine how many clinicians might have been afflicted with the 'human error' label when the actual reason was the system.

Now, if you were remotely responsible for patient safety, you will now rush out into your healthcare facility to make sure that you have only type of numerical keypads at your facility for these. That is at the narrow level. At the intermediate level please ask yourself how many other items that are non-standard at your place of work that confuses people and compels them into making an error. Go looking for them and eliminate them.

At a bigger picture level we are beginning to believe that 'Human Error' is often a cop out clause for managers who don't fully understand systems or processes. To err is indeed human but to design for failure and then blame it on 'human error' is inhuman.

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PS: Note the manufacturer of the pumps in the picture above is only an illustration to make a wider point, those pumps are good and overall have served patients well.  So please do not get hung up and pious about a particular product or company. I have also found that my windows calculator and my samsung phone calculator have different numerical keypads which are different from my computer keyboard's numerical keypad. How confusing is that? Is it any wonder then if some poor bloke at the office goofs up? 

Friday, 7 December 2012

Examinations for doctors - time to think differently

I wrote the article below in 2006. I was not blogging at that time so it just lived in my computer. When you read it please be in a 2006 frame of mind. The article 14, the new rules for surgical exit exam, the impeding new contracts for doctors especially for SAS doctors and so on.

Once you have read it, cross reference it to the recent GP exam results.

We need an end to the monopoly of examination providers for post-graduate doctors. We need a plurality of avenues to demonstrate knowledge.  Why should every university in UK not have a knowledge test for specialist doctors?

The link to the intercollegiate website cited in the article will not work, you may want to search their website for the current link or otherwise check with them.



The surgical royal colleges have decided to allow any candidate who is able to muster the references of two consultant surgeons to take the intercollegiate exit examination. The colleges would see this as a response to the changes in the rules that have happened due the PMETB to allow a fair opportunity to anyone who wants to demonstrate their proficiency in surgical knowledge. The General and Specialist Medical Practise Order that created the PMETB was passed in April 2003 and there have been wide consultations before and since. It has taken three years to arrange a new format which is likely to change again very soon, in view of the MMC reforms.

While it is clear that the 'standard of knowledge' should be the same for surgeons entering the specialist register one has to question if the actual examination should also be the same. Whether different formats for differing groups/sub-specialties were considered is not known. Whether any surgeons who are not in training were consulted before these changes is not known. If any of the 'mediated entry' candidates who have taken these examinations in the past were consulted is not known. A close look seems to reveal the need to have some radical, new and different thinking about who should take which examinations and who should offer them.


The point about consulting the past candidates is rather important. The evidence for the importance lies in the figures available in the Intercollegiate Speciality Boards website ( where between 1998 and 2001 the overall pass rates in the intercollegiate surgical exit examinations was 70% for mediated entry candidates, 76% for type two trainees and 96% for type one trainees. We should keep aside the issue of mediated entry candidates for just a moment and look at the glaring difference of pass rate between type 1 and type 2 trainees. Most type two trainees worked to similar rotas in similar hospitals with similar consultants and mostly for similar number of years. Some differences do exist in their pathways such as type one trainees spending more time in teaching hospitals and type one trainees having experience in some research, while many type 2 trainees also have such exposure not all of them do. Opportunities for courses, learning etc are all similar. However, when it comes to examinations type 2 trainees did not do well. It begs many obvious questions, the foremost of which is why trainees with such similar pathways did not fare similarly at the examinations. If type 2 surgical trainees had equivalent training to type 1 trainees, as an admission to the examination implied till recently, why did they not do well? If we accept that the examination was a true reflection of their training and knowledge then was the process that selected them was wrong? If we accept that their pathways were not as similar as described here then why were they allowed into the examination on the basis of ‘end of training’ ‘exit’ examination? Knowing that type 2 candidates fared badly what changes were made to address that situation? If they were genuinely poor why were they selected into specialist registrar posts, if they continued to be poor why were they not stopped from progressing through their training which enabled them to take the examination?

When so many questions exist in the issue of type 2 registrars, there are even more for mediated entry candidates of the past and especially possibly for non-training post holding candidates of the future.


The debate is not simply about the present UK based SAS doctors, FTTA, LAT and LAS posts who intend to take these examinations under the new regulations. The future also demands some answers. Some of the colleges have taken upon themselves to hold these examinations in many parts of the world. The demand for such examinations exists. Would the colleges allow non-training doctors from abroad to sit the intercollegiate exit examinations? This opens an even wider debate whether surgeons not in non-training posts from anywhere in the world would be allowed entry in to the specialist register partly on the basis of a test of knowledge that UK Royal Colleges offered. That is not to say that such surgeons should not be allowed but to wonder if the GMC, PMETB and royal colleges have the resources to probe the credentials of such candidates so thoroughly that the British public can be assured of quality in real time practise and not success in a paper work exercise. Perhaps the easy way out is to ‘rule’ on application, that the applicant is in need of further training, which is in reality will be difficult and expensive to challenge by overseas applicants.


The law in the form of the PMETB rules allows for various types of demonstration of knowledge, specifically to enable a variety of suitable candidates to enter the specialist register. The surgical colleges instead of taking the cue and innovating, have changed the entry criteria and the format to allow non-training surgeons to sit the same examination. Instead of exploring and enabling diversity that the law demanded the situation is now quite simply similar to tying the hands of a challenger and then putting him into the boxing ring. The example of an SAS doing excellent breast work for years taking the exit examination as an opportunity and achieving a predictable failure can be foreseen very clearly. To state that it is the responsibility of the candidate to ready themselves in all aspects before appearing for the examination sounds very reasonable but in reality very cynical. To then retrain the candidate due to a PMETB refusal or an examination failure and on the successful completion of 'training' and/or 'examination' only to be employed to the same job but possibly a higher title seems bad logic and an extreme waste of resources.

There is also a general perception that the current format of the new examination could be interpreted as being that of a different standard than the recently expired one. There is a suspicion that the goal posts are set differently in preparation for the MMC changes.


In the UK there is only one form of test of knowledge. There is only one body that provides it. This situation may be appreciated as offering uniformity. On the other hand it could also be considered as a monopoly of provision. The general view of monopolistic provision is that it is unhealthy. The intercollegiate format could also be perceived as cartelisation of sorts. The reality of a very small number of people involved in taking these examinations may prevent such a thought stream from developing into meaningful progress.

Surely the royal colleges have huge experience in designing examinations and though a challenge could devise a range of 'fit for purpose' examinations which would be of equivalent standards to enter the specialist register. The law allows it though does not require the colleges to do so. Coming from a different angle would it not be logical to wonder why a breast specialist has not taken a specific exit examination in breast surgery and so on? The urologist does.

More and more of assessments are being delegated and devolved to local deaneries who then sub-delegate to individual trusts and consultants in the form of in the work place assessments. As a logical futuristic extension some consideration may be given to decentralising the test of knowledge to be provided by a range of alternative providers. This may be not only a great market opportunity but also an opportunity to demonstrate leadership and vision, for universities and private educational systems to device such tailored high standard tests of knowledge as they have already done in the CME/CPD areas.


No one argues the need for good knowledge before entering the specialist register; it is no doubt a must. The entire debate is about the demonstration of that knowledge. The intercollegiate surgical exit examination is one of them but it is probably suited only for the current type one trainees. That examination's suitability for others including type 2 trainees and their derivatives, the future MMC defined ST post holders, SAS surgeons, MMC generated non-training post holding surgeons, overseas non-training post holding surgeons is unclear, though many will take it due to lack of alternatives. There may also be reluctance on the part of the ‘higher’ authorities to accept alternatives.

It is time to realise that 'similar' and 'equivalent' do not have to mean doing the same things or taking the same examinations. It is possibly the time to wonder about the paucity of alternatives to demonstrate knowledge. With the large increase in the number of medical students and the possibility of expansion of ‘consultant’ numbers, it is time for the good and great of the medical profession, though the surgical example is illustrated here, to lead in thinking, policy and practise rather than to react and respond as shown repeatedly with some of the glowing examples such as Calman, EWTD, PMETB and MMC amongst many others, with many issues arising from them still remaining unresolved.


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Saturday, 1 December 2012

Revalidation - GMC must make it objective as soon as possible

The shortest overview of revalidation

GMC is commencing the process of revalidation for doctors in December 2012. The revalidation demands that we have evidence of 

1) Continuing professional development
2) Quality Improvement Activity
3) Significant events
4) Feedback from colleagues
5) Feedback from patients
6) Review of complaints and compliments

These six will populate the annual appraisal which apart from its main domains include the personal development plan, probity and health

Based on the above, the responsible officer will make a 'judgement' on whether the doctor can be recommended for revalidation. The GMC will then make a decision on whether the doctor has been successfully revalidated.

There is plenty of guidance on GMC website :

Concerns about the background for revalidation

While the issue of periodic quality assurance of licensed doctors has been discussed for a long time, the common view is that the current revalidation efforts commenced after the Bristol enquiry and gathered momentum after the Shipman enquiry. Bristol was an outlier, there was no trend that many hospitals or many cardiac surgery units were having unacceptably bad outcomes. Shipman was an outlier, there was no trend that many doctors were behaving or beginning to behave in a Shipman like manner. Outliers need to be analysed properly so that outliers can be stabilised to a performance level compatible with other performers within the general system. Quality principles would suggest that outliers should not trigger a process change for the whole system. Process change for a system could be triggered by an unacceptable trend (there are other reasons to change the process as well, but outlier is generally not one of them). To create a process change on the basis of outliers is thought to result in unnecessary expense and wasted effort.

This does not mean that we cannot learn from outliers, undoubtedly there are extraordinarily important lessons to be learned from Bristol and Shipman.

Linking the background to current revalidation method

Bristol is about performance and Shipman is about behaviour. We can safely assume that this is what the GMC seeks to assure. Quality assurance needs to be demonstrated in an objectively measureable manner.

Revalidation criteria - Not Objective

The six areas of evidence that the GMC asks for seem to be mostly subjective.
Continuous professional development (CPD) is generally accepted as a reflection of time spent on courses and conferences or other learning opportunities. It is certainly not a measure of the knowledge or skills gained or updated though that might happen. Some professional bodies have not defined the time needed to be spent on CPD. Hence while CPD is often measured and entered as a number it is a measure of time spent rather than a number to show the knowledge or skills gained. It could therefore be argued that CPD is either subjective or fit for purpose for revalidation if the intention was to validate or assure knowledge and/or skills.

Quality Improvement Activity: within this areas a range of activity is included. Activity is neither outcome nor achievement. Therefore activity is again time spent rather than gains (or losses) measured. An important point in quality improvement activity is that people fail more often than they succeed, that is the nature of quality improvement. Doctors, hospitals and the GMC should be comfortable with that. This could be potentially be an objective criteria but currently it could probably be considered unsure.

Learning from significant events and review of complaints and compliments are about self-reflection and reflective writing. It is obviously subjective. Feedback from colleagues and feedback from patients though done through validated tools by external or independent service providers is essentially the conversion of subjectivity into a scale to be able to measure.

Are subjective criteria relevant?

Absolutely yes. But only when looked along with objective criteria. Any form of quality assurance process must include subjectivity. The current criteria for revalidation seems mostly subjective and hence the concerns.

Why are objective criteria important?

We are talking about doctors who are essentially already very highly qualified and doing an extremely complex job under phenomenally varying conditions. We are taking about professionals on whom we have already spent somewhere between half-a-million to a million pounds before they are employed to do their role. Revalidation is about making a decision about their careers which could potentially be halted. To make such major decisions on mostly subjective criteria would not make sense. Further, there are planet loads of data already gathered and analysed and hence objective criteria are possibly already available if we wanted to use them.

Next is the issue of who may potentially be adversely affected to a higher degree than most. When subjective criteria are used there is a risk that often the weak, the easy targets and usual suspects may be affected. This has been seen in a few exam situations where certain sections of candidates pass the objective knowledge and skill components but fail the subjective elements of vivas, communication, simulation etc. There is a fear that it is possible that IMGs and BMEs (and SAS) doctors  would be affected by the level of subjectivity involved in revalidation.
There are good reasons behind these fears which relate to the culture and history of healthcare institutions and the culture and mind-set of BME/IMG doctors which is not explored here.

Increasing objectivity

Testing knowledge has traditionally been done by examinations. Americans revalidate their doctors on the basis of an objective examination of knowledge. This while reducing bias increases the validity of assurance of knowledge. Skills assessment could quite relevantly be based on performance data. Speaking from a hospital doctor perspective, this should be quite easy to do with some minimal tweaking on how data is gathered. Operational performance data is either the best or as good as any other indicator of a doctors skill.

Increasing objectivity still would not resolve the underlying issue of a process change for all doctors based on outliers and not trends. The GMC also needs to resolve other issues. Is revalidation a quality assurance process or a quality improvement process? Because the theory and the tools for assurance are different from improvement

Revalidation is important. It is likely that as it stands the revalidation process is heavily subjective. Given the importance of healthcare of the nation it would be advisable to quickly move to mainly objective criteria. We are where we are, let us make it better and fit for purpose.

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Wednesday, 14 November 2012

Virtues of doing nothing

In article titled 'Buffet succeeds at nothing'  Buffet fan and investor Mohnish Pabrai writes about the need to avoid reacting to every little flicker of the ticker, enjoy long periods of relative quiet and inactivity. Sitting on their butts as they put it. Apparently it is beneficial, well of course it is, it made them very rich.

I love it when Pabrai says 'Eventually the nerds got fidgety....'. High intelligence and high skills can sometimes be an high intensity problem - people want to use their intelligence and skills often. They want to prove it often to themselves - a need to pamper our egos. They want to show off to lesser mortals around them - the feeling of superiority gives us a true 'high'.  This leads to the cleverer ones doing things when the better option would be to actually do nothing.

Masterly inactivity is well known to doctors especially who are obstetricians. Anaesthetists achieve excellent safety in the administration of general anaesthesia and we know very well that for most general anaesthetics there are brief periods of intense activity followed by long periods of studious and judicious inactivity. However for many other doctors there is the desire to do something. That sometimes actually achieves good results for patients. However, this urge to do something also results in unnecessary investigations, overdiagnosis, un-indicated procedures, too many follow up appointments, wasted education programmes, mere activity replacing achievement, medicalising normality, therapeutics for the false positives, narrower sub-specialisations,.............. Do I need to go on?

In quality improvement theory, to intervene when not indicated is actually called tampering, which is inevitably a waste of time and could be seriously harmful. The term inactivity is actually used with caution here, it does not mean completely switching off and going to bed, it means that we need to observe the effects of action. Once an action is initiated, it takes time to see its effects, it takes time to gather data, it takes time to analyse the data, it takes time for trends to develop, it takes even more time to understand trends and it takes a lot longer to decide on how to respond to the trend analysis. The frame of time of course varies depending on the activity; seconds, minutes, hours, days, weeks, months, years, etc

Most of us have no respect for this line of thought and would react to individual events rather than proper trends. Anyone who has studied some decent management would have learned that the cost of indecision is higher than the cost of a decision. This is taken as a call for action, often hasty, often unindicated. The decision not to act before it was necessary is a wise decision, this is often mistaken by fools as indecision. I would say the cost of unindicated action is higher than the cost of indecision. 

The importance of doing nothing is especially acute in clinical medicine and healthcare. We have in Clinical Wrongology already touched briefly on the lack of evidence for most of the activity we do in clinical care, the high rate of errors in clinical care delivery processes, our inability to agree with our colleagues and our lack of acceptance of these issues. Logic demands that under these conditions we should often do nothing, since doing something is more likely to be wrong. To act hastily under these conditions and to react to every point rather than proper trends is indeed a recipe for disaster and adds to the wrongness in healthcare.

Whenever there is a choice between action and inaction the cleverer ones chose action. We all know for every action there is an equal and opposite reaction. That reaction may neutralise the effect of the action or worse cause harm. To do or not to do, becomes a very relevant question for clinicians. To do something when doing nothing would be better requires a higher level of maturity and judgement apart from better operational evidence. 

Do be very discerning in understanding this blog, I am not saying we should not act when the situation demands it. I am asking you to think if we act even when the situation does not demand it, if we do, then I am arguing that there may be virtue in doing nothing.
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Wednesday, 31 October 2012

Guarantees in Healthcare

I would like you to take a moment to think about what is the longest guarantee period offered for a product that you know of. Months, years, decades? What about life-time guarantee? For instance Toyota offers an 8 year guarantee for their Prius battery for the electrical motor part of their hybrid system. Some manufacturers and some body works repairers offer life time rust proof guarantee. Pizza companies say that you can have the pizza for free if it does not reach you within a defined time after your order. Well you can surely name a few more yourself.

Here is a jaw dropping guarantee. 2000 years.

Yes, you read it right The Sweet Little Sugar Softener offers a 2000 year guarantee. Yes that is offered for a product that is very simple. Okay, I am not sure if any of us are going to be around for 2000 years to vouch for this. But just imagine the confidence of the manufacturers in their product that they are able to offer it. It is a product made by simple artisans in rural America, not highly educated, with no great facilities etc

Guarantees in Healthcare

Health care is full of educated, highly intelligent and motivated people. Many if not all clinicians would have two post-graduate degrees. Healthcare managers and insurers are very large players in terms of the total money spent on healthcare especially in the western world. What kind of guarantees can healthcare offer to patients? As far as I know, none. In fact, professional bodies may not look at you very kindly if you started offering any guarantees, they will come down on you with a tonne of heavy scientific bricks and with a high moralistic tone accuse you of potentially misleading patients. Why is that? Why is it that healthcare which consumes so much of our resources unable to offer any sort of guarantees to our patients?

It is high time that we started backing our intelligence, education and skills and experience to think about what guarantees we can offer our patients and how we can make those guarantees work. We then need to put some money to back those guarantees. Doctors should perhaps take the lead on this one. Doctors always claim that they are consistently in the top 2% of the top performers in the society - well that is indeed true. If the top 2% performers cannot guarantee any of the activity they do and back it with some money we do need to either question their performance or their motives.

Healthcare needs some guarantees, patients need some guarantees. Yes, you healthcare folks, time to up your game, I know you cannot yet reach the level of guarantee offered by rural native American artisans but surely you could start with something small. How about no charge for patients if their bowel anastamosis leaked? How about completely free care if you did not meet the expected discharge date? How about paying a penalty to the patient every time you cancel or postpone their appointment/operation/etc.

Healthcare just dazzling and blinding people with asymmetrical power, high intelligence and skills is not simply good enough any longer. It has to be matched with some performance guarantees.

Being the change you want to see - the oft repeated Gandhian saying; on that basis let me go first.

(possibly for the first time in the world)

One day the whole of healthcare especially doctors including me may be able to offer guaranteed clinical end results; right now it seems we cannot. So what can I guarantee can I give my patients? Before we get into that let me also explain that I work in the NHS on a salaried basis in a surgical department. NHS allows me to do private practice but I am not in regular/routine private practice. I cannot as an NHS doctor offer any individual guarantees to my patients. I am like the rest of the British people, own the NHS but do not run it. However I can offer some guarantees to my potential private patients.

Here are the guarantees I am willing to offer to any private patient who cares to find me and pay me a fee for service (self paying private patients).
Open primary inguinal hernia repair: if you have a recurrence within 3 years I will refund you the my fee i.e. the surgeon's fee.
Colonoscopy: if I do not reach the caecum (provided it was not poor bowel preparation or a confirmed bowel narrowing) and hence you had an incomplete colonoscopy I will not charge you my personal fee for the procedure.
Obviously all other charges will apply, have to be paid for and not be refunded.

As I have already said, right now I am not in active private practice. But if there were any patients who paid me privately for these two procedures that is the money back guarantee I am able to offer. If there were takers for this service/offer I might be stimulated to think of what further guarantees can be designed in healthcare.

What is important is if many others in healthcare provision are able to offer firm money back guarantees in healthcare. That might be a disruptive innovation in clinical provision. Let us go for it.

What are the guarantees that you are able to offer your patients?

Update: 1 Nov 2012: W Fischer informs me that there are guarantees in healthcare at Geisinger, Danville, PA since 2006. Very nice to know. So obviously I am not the first or the only. Here is a write up on their warranty: There are press stories about it, find it on the net. They do not seem to pay the patients any money back (I suppose that will be an issue for the insurers) but they do not charge the insurer to fix any complications.

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Wednesday, 17 October 2012

Mark the site campaign


A Surgeon's interaction in the Operating Theatre

This is a real conversation that happened in a real surgical operating theatre in India a few weeks ago. It probably happens every day.

Surgeon, standing to the right of a patient under general anaesthesia for hernia repair asks: 'which side is the hernia?'

Assisting surgeon: 'I don't know. I did not see the patient.'

Surgeon: 'Who saw the patient?'

Assisting Surgeon: 'The house surgeon from the previous shift'

Surgeon: 'What does it say in the notes and consent?'

Assisting Surgeon: 'Hernia repair, obviously'

Surgeon in anger: 'Obviously!! But which bloody side?'

There were a large group of people in that operating theatre, junior nurses, medical students and other staff. None of them will speak to the chief unless they are spoken to. Silence for a few moments.

Surgeon in exasperation: 'Does anybody know the side?'

Medical Student puts her hand up.

Surgeon very impatiently: 'Tell us. What are you waiting for?'

Medical student says: 'I don't know for sure, but I was standing on the right of the patient's bed when I examined him and I had to reach out across to feel the hernia. So it must be the left side.'

Surgeon: 'Left it is then. Let us get this done'

Very lucky day. The patient did have a left hernia. The medical students had seen two other hernia pre-op patients the same day and extremely fortunately they were all left groin hernia.

Wrong Site Surgery WSS
(and wrong site procedures: wrong site anaesthetic, implement fitting, etc)

Sadly not all patients have lucky days like the above patient.

Wrong site surgery is estimated to happen once a year in a typical hospital with 300 beds Clarke, J.R., Johnston, J., and Finley, E.D.  Getting surgery right.  Annals of Surgery;246(3):395-405, Sept. 2007.

Surgeons have a 1 in 4 chance (i.e a very high chance) of being involved in a wrong site incident

Wrong Site Procedures: Wrong side anaesthetic – is happening more and more with not much attention paid to it. There are a number of interventions done in wrong patients, a large number of unnecessary procedures done on right patients. Even the statistics for these are difficult to find.

Though the evidence comes from the west there is no reason to believe that other countries (such as India) have any less incidents or better practices.

The impact of these are dreadful with life long suffering. Life long dialysis if the wrong kidney is taken out or a kidney transplant with the complex lifelong medication to be taken after that, wrong eye – blindness, wrong leg, etc. It does not need to be major operations even after lesser wrong procedures it is possible to have wound infections, chronic wound pain etc. These are just physical. The psychological effects are much worse and affects not just the patient but families, friends and whole communities. Trust in healthcare providers – hospitals, doctors, nurses – irreversibly damaged.

The internet is full of events, episodes and tragic histories of patients who have suffered wrong site surgery. If you want examples they are only a couple of clicks away.


It is very easy to write about solutions but it is well recognised that any solutions against wrong site surgery is very difficult to put into place, difficult to practice and not always successful. That is no reason not to try to reduce it by any means possible.

Some of the more effective solutions are thought to be:

The operating surgeon to see the patient on the day of the surgery and MARK THE SITE on the incision or as close to the incision as possible.

If the procedure involved a symmetrical organ the opposite side i.e. the side without the pathology is marked with a big NO; that may help.

Some surgeons write the name of the procedure (including the side if appropriate) on the incision line – that helps.

Check lists that include surgical site marking

Improving the culture so that any member of staff however low down in hierarchy is able to speak up when WSS issue is suspected

Our own suggestion (though not research based) is to empower the patient by asking a competent patient (any one who is able to give consent should be a competent patient) or a competent relative to mark the site of the procedure in the presence of the operating surgeon. After all it is reasonable to assume that the patients have a vested interest in the surgeon not operating on the wrong part of their body.

Even if it is a non-symmetrical organ procedure or a midline procedure make it a habit to mark the patient so that you can have standardised preparation protocol. It will really help a patient some day, if you are a doctor it will surely help save your career.


This is a campaign we are specifically starting for South Asian countries (e.g. India) but is also relevant to many developing healthcare systems (e.g. African continent).


Please pledge today that you will mark the site of the incision on all patients on the day of the surgery.


Please pledge today that you will not begin anaesthetising a patient unless you see the site marked on the patient's body. If there is no mark please ask your surgeon to check and mark it before anaesthesia is commenced.


Ward Nurses: Please pledge today that you will not let any surgical patient leave your ward to go to operating theatres unless their surgical incision site is marked by the operating surgeon.

Theatre Nurses and allied theatre staff: Please pledge today that you will not allow patients through the main doors of the theatre unless you see the surgical incision site marked.

PATIENTS (and relatives)
Please pledge today that you will not leave the ward/bed and enter operating theatres unless there is a mark on your body at the surgical incision site.

Pharma companies and their sales reps
Please provide doctors with a skin marker pen as a part of the various complimentary items that you provide and ask the doctors to use them to mark the surgical incision site


Please forward the link for this blog to at least two persons. Alternatively cut and paste and send the information to at least two persons.

Write to hospitals, politicians, news media outlets or any other action that spreads the message.

Let this be a campaign be owned by us the normal public (such campaigns are normally lead by institutions/organisations/etc)

Primum non nocere is a fundamental principle of medical practise. Causing permanent harm by wrong site surgery is against that principle. It may not have happened to you yet but look at the numbers it is happening all over the world, it may happen to you unless you take definite action about it; irrespective of whether you are a healthcare professional or general public.


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Sunday, 7 October 2012

Increased Quality and Reduced Cost - Possible in India

I have a long held view that quality is inversely proportional to cost which means as for a given activity as the quality improves cost decreases. This is actually possible in India as well.

Let me share a clinical anecdote that may illustrate my point. It may be dated and trivial to many current readers but was very relevant to the patients and clinicians at that time.

In the late 1990s I was working as a surgeon in Sir Ivan Stedford Hospital, Ambattur, Chennai, India ( This is a charitable hospital where we used to charge very small nominal amounts of money to provide services. A few rupees for out-patients, few tens of rupees for scans and so on. Being India, one of the commonest operations performed happened to be surgery for hydrocele. The way it was conventionally performed may be very familiar to many of you. The operation of course ended with a large bandage tightly applied to the scrotum with the purposes of avoiding problems like pain, infection, haematoma, oedema etc. These patients were also put on antibiotics for 10 days or more. Many of these patients used to come back with soiled dressings and the exact problems that doctors were trying to avoid. Doctors used to wonder what else could be done to improve the situation.

Not using a bandage was thought to remove an all important barrier that avoided exposure of the scrotal wound to the unhygienic toilet situation in India and despite using 10 days or more of antibiotics infections were happening. Barrier and antibiotics thought to be bulwarks against contamination and infections were not working.

I actually thought the tightness of the bandage caused oedema and increased pain. The presence of the bandage increased sweat and moisture in an already humid perineal area in a warm country. The bandage also easily became wet because of the toilet washing habits of the country and acted as a rich environment to create infections.

Having worked in England where the scrotal bandage was not routinely used after scrotal surgery, I took the bold step of not using scrotal bandages to hydrocelectomy patients much against the advise of my friends and colleagues. Of course, I suggested the use of the proper scrotal support clinical hosiery which was either not available or when available was very expensive. An alternative had to be found. I simply asked my patients to buy 7 of the cheapest 'A' or 'Y' front underpants from the shops opposite the hospital otherwise I would not operate on them. I used these normal commercially sold underpants over a couple of pieces of sterile gauze placed on the scar, changed once a day by the patients themselves, in the place of scrotal bandages for my patients changed by clinical people. Most of my patients found this very amusing. Some were resistant, perhaps hesitant, because the had not worn such a type of undergarment before. My colleagues were of course greatly humoured by what they thought was my naivety and enthusiasm.

In a few weeks, post operative follow up clinics were showing that my patients were walking in and walking out in super speed and for the rest of the surgical team there remained the usual levels of post op problems with pain, oedema, infections. Having eliminated the scrotal bandage which I thought was causing the problems, I then moved to single dose prophylactic antibiotic as I used to do in Britain.

Word of mouth and social observations in a local context those days was of course as fast as twitter or facebook now. The talk was about how patients spent less money on changing bandages and buying antibiotics while getting good results. Soon my colleagues avoided scrotal bandages, used undergarments as I recommended and moved to a shorter course of antibiotics often just 3 doses (instead of the usual 10 days).

Of course the people who charged for the change of dressings and the people who sold antibiotics were not happy. But I can tell you who were happy, the guys who sold the undergarments. They were really happy. 7 undergarments per hydrocelectomy patient in a hospital that did hundreds of hydrocelectomies, they must have been ecstatic. Well, I know they were, as one of them approached me and offered a commission to me (his bloody nerve) if I could recommend patients to buy the undergarments specifically from his shop – no different from the drug store chap then!

Clinical complications reduced – i.e. quality improved. Cost reduced.

Okay, this example is not about whole systems, scientific proof, published evidence and other high & mighty things. It is one little example. What I cared and what our patients cared is that we had lesser clinical problems and we achieved it by doing/using/costing less. Perhaps hydrocele surgeons in India are no longer using scrotal bandages and 10 days antibiotics - that is why this anecdote may be very dated but the general lessons are in my view still valid.

Increasing quality while decreasing costs can be achieved in India as well. Perhaps due to the large number of people who are around the poverty line this concept becomes even more relevant to India. We must remember that though the GDP is high the per-capita money is very low in India. Individual doctors are not dealing with the mighty high GDP India; individual doctors deal with the individual patients of low per-capita India. That is why low cost high quality care becomes essential.
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