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- Cognitive Errors ("Mistakes")
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Yi Lu, MD, PhD, and Douglas Salvador, MD, MPH; August 2019
A woman with a history of prior spine surgery presented to the emergency department with progressive low back pain. An MRI scan of T11–S1 showed lumbar degenerative joint disease and a small L5–S1 disc herniation. She was referred for physical therapy and prescribed muscle relaxant, non-steroidal anti-inflammatories, and pain relievers. Ten days later, she presented to a community hospital with fever, inability to walk, and numbness from the waist down. Her white blood cell count was greater than 30,000 and she was found to be in acute renal and liver failure. She was transferred to a neurosurgery service at an academic hospital when an MRI revealed a T6–T10 thoracic epidural abscess.
Biel L. ProPublica. October 2, 2018.
This news article reports on systemic weaknesses that enabled a surgeon with poor skills to continue to perform procedures after numerous surgical errors that resulted in patient harm. A past PSNet perspective explored the risk of recurring medicolegal events among providers who have received unsolicited patient complaints, faced disciplinary actions by medical boards, or accumulated malpractice claims.
Journal Article > Study
Howard BM, Holland CM, Mehta CC, et al. JAMA Surg. 2018;153:313-321.
Overlapping surgery refers to the practice of surgeons scheduling two procedures performed on different patients concurrently. This practice has raised safety concerns in light of news investigations, which prompted a government inquiry into concurrent surgery policies. This single-center retrospective study of 2275 neurosurgery cases at an academic medical center compared overlapping to nonoverlapping procedures. The majority of surgeries were overlapping, and rates of morbidity and mortality did not differ between overlapping and nonoverlapping cases. These findings suggest that overlapping surgery can be conducted safely.
Marsh H. New York, NY: Thomas Dunne Books; 2015. ISBN: 9781250065810.
This intensely personal memoir by the famed British neurosurgeon Henry Marsh is no hagiography or recitation of his many accomplishments. Instead, Marsh relates many errors he has committed or witnessed, and the personal toll these errors have taken on his patients and himself. He recreates these stories in vivid detail, acknowledging the effect that his own emotional state had on committing both cognitive and technical errors. Marsh was inspired to write this book in part by reading the work of Daniel Kahneman, the Nobel Prize–winning psychologist whose research established the mechanisms by which humans commit cognitive errors. Along with Atul Gawande's Complications, this book stands as an essential human perspective on error in medicine.