The contemporary patient-safety movement has focused almost exclusively on systemic causes and solutions for medical errors, taking care not to point fingers at individuals.
“This is not a ‘bad apple’ problem,” the Institute of Medicine’s “To Err is Human” report brief said. “More commonly errors are caused by faulty systems, processes, and conditions that lead people to make mistakes or fail to prevent them.”
This approach has given birth to an array of initiatives to reduce patient harm, virtually all of them aimed at hospitals or teams working inside them. They include using safety checklists for basic procedures, handwashing campaigns and urging medical team members to speak up when they see problems.
Few would dispute the value of these steps. But Medicare and accreditation organizations haven’t required hospitals to comprehensively track patient death rates and complication rates by doctor. Beyond meeting some minimum standards, hospitals are free to decide how much of this information to collect.
As a result, most hospitals’ monitoring of surgeons is “rudimentary,” said Dr. Ana Pujols McKee, chief medical officer of The Joint Commission, the nation’s largest hospital accrediting organization.
Some experts say it’s time to put more emphasis on the role of individual practitioners.
“The idea that it’s all systems and there are no individual performance differences is absurd,” said Dr. Robert Wachter, chief of medical service at the University of California, San Francisco Medical Center and a nationally known expert on patient safety. “A good system has a mechanism to identify poor performers and either make them better or get rid of them.”
ProPublica analyzed 2.3 million hip and knee replacements, spinal fusions, gallbladder removals, prostate resections and prostate removals done between 2009 and 2013 on patients in Medicare, the most comprehensive source of national hospital data publicly available. Medicare pays for two out of every five U.S. hospital stays, and researchers routinely use the program’s data to study the health care system.
Because there are many ways to define a surgical complication, we consulted with two dozen physicians to identify those that are directly related to each of the operations. These include infections, blood clots, misaligned orthopedic devices and uncontrolled bleeding. We then counted only cases in which the patient died in the hospital or had a complication requiring readmission within 30 days.
The American College of Surgeons has said surgeons are responsible for all aspects of their patients’ care, from preoperative examinations to complications that can arise after the operation. Dozens of surgeons and patient safety experts interviewed by ProPublica agreed that surgeons can reasonably be held responsible for complications even if they are not directly at fault.
ProPublica’s analysis has some limitations. Patients covered by private insurance were not included, which in some instances omits a substantial portion of a surgeon’s practice. And our definition of complications does not cover other types of patient harm, such as diagnostic errors or readmissions more than 30 days after an operation.
Still, the five years of data document a costly human toll. About 63,000 Medicare patients suffered serious harm, and 3,405 died after going in for procedures widely seen as straightforward and low risk. Taxpayers paid hospitals $645 million for the readmissions alone.
George Lynch nearly died from complications after a 2013 knee replacement. Lynch opted for a surgeon at New York Methodist Hospital near his home in Brooklyn. He couldn’t have known what ProPublica’s analysis shows: The surgeon, Dr. Henry Tischler, had one of the highest complication rates on knee replacements in New York State.
Lynch contracted multiple postsurgical infections and went into septic shock. He says his family, told he might not survive, came to the hospital to say their final goodbyes.
Tischler did not respond to a request for comment. New York Methodist said in an email that Tischler “sees some of the most challenging cases in the region, and goes to great lengths to ensure that each patient receives the best possible care.”
Lynch eventually recovered, but he now needs another knee replacement. This time, he’s peppering his doctors with questions and said performance data will help guide his choice of a surgeon and a hospital.
“I’d rather be a difficult live patient,” he said, “than a compliant dead patient.”