Quality Assurance Scapegoats
Quality assurance is the name given to the various ways designed to protect the public from bad healthcare. There are many organizations responsible for quality insurance, from state medical boards to hospitals. What happens when these organizations responsible for protecting the public fail to do so?
You may have read the story of Dr. Thomas Shaknovsky. Initially, this news simply reported about a doctor who removed a liver instead of a spleen and the patient died. The operative report described the procedure as a splenectomy. However, the pathologist following up on the patient's death identified that the organ removed was a liver, not a spleen.
Now we have news from the other people in the operating room telling an entirely different story. As a reader, I suspect the second story is more truthful than the first. The surgery began as a laparoscopic procedure to remove the patient's spleen. Apparently, the colon was distended, obscuring the surgeon's view, so an open procedure was started. The colon was still obscuring the surgeon's view of the spleen, but operating room (OR) personnel retracted the colon out of the operating field.
The doctor apparently identified the vena cava, a very large vein carrying blood from the lower part of the body to the first chamber of the heart. According to OR personnel, the doctor commented that he could feel a pulse below the vena cava. He used a mechanized clamping device to shut off the vena cava. After that there was significant bleeding from the vena cava, which is the largest vein in the body.
In my surgeries I always avoided having anything to do with the vena cava or other large veins. During my residency at the University of Minnesota I saw what can happen when the vena cava is opened during a procedure. The problem with big veins is that they are very hard to sew and even a small, two-millimeter cut (22 millimeters in one inch) can produce torrents of blood. The vena cava is about as thick as cellophane, so every time a suture is made, there are two more holes for blood to squirt from.
Not only did Dr. Shaknovsky clamp off (ligate) the wrong vessel, but he also used the wrong tool. In other words, clamps are used to shut off a vein on both sides of a vessel, not just one side. Apparently, Dr. Shaknovsky used a clamp to ligate only one side of the vessel he was going to remove. Ligating only one side of the vena cava would cause massive bleeding. Ligating both sides of the vena cava before and after the organ being removed would have resulted in no bleeding from the vena cava, but would still have been an extremely serious error.
There are two issues here which are very important. The first is that we must suppose that everybody else in the operating room saw the problem. In other words, it doesn’t take a lot of intelligence to understand that this procedure was going terribly wrong.
Rather than OR personnel helping to correct any of the errors, they watched the surgeon continue to make errors. They should have recognized that intervention was needed and acted to correct and prevent more errors, not simply watch Dr. Shaknovsky continue to make errors.
If the OR nurses, anesthetists and anesthesiologists knew Shaknovsky was making surgical errors and later making false OR reports, they had the ethical and moral obligation to call in help. They had the ethical and moral obligation to call in some other surgeon who could have intervened. The OR personnel failure to report these kinds of mistakes go way past the issue of quality assurance. This is an issue of simple intelligence, ethics, and morality.
Dr. Shaknovsky had done surgeries at this hospital before. It’s extremely unlikely that the errors reported in this surgery were his first.
It’s much more plausible to believe that Dr. Shaknovsky had a standard of inadequate practice which everyone in the operating room as well as the other surgeons at this hospital knew about. Indeed, the hospital chief of staff and the hospital CEO should have known about Dr. Shaknovsky's surgery skills and probably did. And if they didn’t know about it, they should have. Ignorance is no defense when lives are at stake. The question becomes why didn’t any of the people responsible for quality assurance appear to do nothing about it?
According to the news articles, a year previously doctor Shaknovsky removed part of a pancreas instead of an adrenal gland. At that time there should’ve been a heightened concern. The state medical board should have been informed. There should have been a plan either to retrain Dr. Shaknovsky in surgery, to supervise him in surgery, or to suspend his license.
Again, the issue remains, why didn’t any of those three actions occur? All of these people who knew or should have known are guilty by omission and maybe commission. They share in this doctor’s guilt in this situation. Doctors do not practice in a vacuum. If there’s a lawsuit, it should certainly involve the entire hospital and all the people involved with the operating room who should have known what kind of surgeries were occurring.
It’s hard to imagine that somebody who does surgery like this actually ever graduated from an accredited program. Training programs have an obligation to not send out incompetent doctors.
The Florida Surgeon General has ordered an emergency license suspension of doctor Shakovsky. Usually these emergency Expartes are done by the medical board. So again, I’m surprised the Florida medical board did not take action. The hospital, Ascension Sacred Heart Emerald Coast, is also complicit, as are the state agencies who are supposed to oversee and manage hospitals.
Yes, if the appropriate safeguards had been undertaken a year ago when Dr. Shaknovsky removed part of a pancreas rather than the adrenal gland, the patient who had his liver removed, would still be alive.
Why didn’t the other doctors, the operating personnel and the CEOs do something about Dr.Shaknovsky's surgery mistakes? They share Dr. Shaknovsky’s guilt. The hospital board, the corporate board, state health department, hospital associations, the Florida state medical board, and even the state legislators share some guilt in this process, because all of these systems are designed to prevent exactly the kind of problem caused by Dr. Shaknovsky's surgery.
So, why did everybody remain quiet? It’s a sad truth that our healthcare system is politically driven by money. When a patient is hospitalized in surgery and hospitalized post-operatively, the hospital makes money. Then the hospital makes money by keeping the patient in the hospital for a day or two. There are doctors who are very busy and some provide poor care, but they bring a lot of surgical patients to the hospital, so they bring in more money than the doctors who are less busy.
In my 40-year experience, I know that there are some very bad doctors who retain their privileges because of the money they bring into the hospital. Little details like taking out the wrong organ are overlooked until you have an absolute train wreck, such as that which recently occurred with Dr. Shavnosky.
After Florida’s Surgeon General did an emergency license suspension for Dr. Shakovsky, the police began looking to determine whether they think criminal action was involved. Making Dr. Shakovsky a sacrificial lamb does not solve the much larger problems here which is the complete failure of multi-system responsibility and management of quality assurance. The Surgeon General’s action gives only the appearance of solving a problem.
It’s fairly typical of State and Federal government to offer a fake solution to a real problem. Dr. Shakovsky is simply the tip of the iceberg. The majority of these kinds of problems reside underwater where they cannot be seen from the surface. Punishing Dr. Shakowsky has the appearance of official state concern for the public welfare while serving to satisfy public interest that the problem has been solved.
Problems in quality assurance which allow medical malpractice like that of Dr. Shakowsky are huge, with multiple layers of responsibility which are only obfuscated by singling out and punishing one person. Many lessons need to be learned from the process of quality assurance. The primary lesson should be that no one person is responsible for failures in healthcare. The many levels of dysfunction in multi-function systems need to be admitted, recognized, and repaired. The fake solution of singling out the doctor (even doctors who should be removed from practice) continues to leave the real failures of quality assurance buried. Pillorying one doctor here and another there is not substantive quality assurance. More emphasis needs to be placed on the multiple layers of failures underlying the real problems in quality assurance.