I think I’m developing a historical crush on Harvey Cushing. This innovative father of neurosurgery was a meticulous record keeper, leaving behind a treasure trove of brain and tumor samples (now stored in a fancy new center at Yale University). Now, from the looks of a new paper, his obsessive note taking has given historians something else: a record of the mistakes and mishaps that plagued the early years of neurosurgery.
In a new study, published in the Archives of Surgery last month, researchers from Johns Hopkins examine Cushing’s surgical notes, looking, in particular, for his documentation of medical errors. As the authors write:
Cushing oversaw one of medicine’s greatest improvements in medical care. His meticulous surgical techniques and attention to clinical observation paved the way for the mortality of the surgical treatment of brain tumors to decline from approximately 50% to less than 13%. Distinct from his publication of complications throughout his career, Cushing’s original surgical records provide a unique benchmark of accountability for mistakes in the files of specific patients during a period of historical advancement and, consequently, also present a reminder of the types of challenges that current safety standards and technological advancements have evolved to address. These century-old cases also offer an early point of reference from which to understand the effect that subsequent events have had on the acknowledgment of medical errors.
The researchers analyzed Cushing’s notes on 845 patients he treated between 1896 and 1912, while working at Johns Hopkins Hospital. Of these, they found 30 cases in which Cushing had clearly discussed operating room errors.
In 17 cases, Cushing documented what the researchers classified as “human errors.” Here are some of the notes Cushing made about those mishaps:
- “A large crowd of interested bystanders and a tired operator led to a mistaken direction of the exploration.”
- “By ill luck or carelessness, the operator retracted the dura to too great an extent and tore off the meningeal artery…”
- “Unfortunately, in withdrawing the needle, it was broken off an inch below the skin.”
- “The operator stupidly did not recognize that this was a new growth.”
- “The button [of bone] slipped and fell upon the operating floor.”
(By the way, that “careless” and “stupid” operator Cushing referred to? Cushing himself.)
In addition, Cushing noted 12 mistakes that researchers classified as “errors in judgment.” In one such case, he wrote: “Throughout this entire performance there was a constant loss of blood. . . . At this period the operator should have desisted but the temptation to continue was too great for him.” The patient died in the operating room.
Finally, in three surgeries, there were failures in equipment or supplies. In one instance, Cushing noted, “We temporarily ran out of wax and had to send across town for some.”
When Cushing practiced, the paper’s authors note, there were few regulations and standards governing medicine, allowing quacks and charlatans to perform procedures alongside well-trained practitioners. Efforts to standardize and improve care raised awareness of medical errors, leading to frequent malpractice lawsuits. And so, it seems rather remarkable that Cushing so thoroughly documented his own mistakes.
This attitude of Cushing toward acknowledging mistakes matches his firm belief in the importance of thorough documentation of poor outcomes. In 1914, he advised fellow physicians: “Statistics are dreary matters, but it is periodically incumbent upon us to assemble our cases not only for our own instruction lest we bury in obscurity our mistaken and bad results, but also to acquaint others with the standing of operative measures. We have become confronted of late years with new surgical problems . . . and, hesitating as our steps may be in meeting these problems, our operative experiences must from time to time be recorded in all their lights and shadows.”
For more on why frank acknowledgment of medical errors is so important–and why few doctors today are as forthcoming as Cushing was a century ago–check out the paper itself. It’s a great, and enlightening, read.
Reference: Latimer, K., Pendleton, C., Olivi, A., Cohen-Gadol, A., Brem, H., & Quinones-Hinojosa, A. (2011). Harvey Cushing’s Open and Thorough Documentation of Surgical Mishaps at the Dawn of Neurologic Surgery Archives of Surgery, 146 (2), 226-232 DOI: 10.1001/archsurg.2010.319
Image: From above paper.