Image of a knee infected with Staphylococcal Aureus Accompanied by a microscopic image of the Staphylococcus organisms

Image of a knee infected with Staphylococcal Aureus Accompanied by a microscopic image of the Staphylococcus organisms

Judy’s terrible experience began with a routine meniscus repair in January, 2007, performed by a respected orthopedic surgeon at a world renowned hospital. She scheduled the surgery early in the year so that she would have time to recover for Spring outdoor activities.  As she pointed out “It could have waited–this was certainly not an emergency.” Unbeknownst to her the hospital where the procedure would be performed was experiencing a sudden increase in the number of infections following arthroscopic surgery. She later learned there was a problem with the equipment sterilizer. And much to her dismay she also subsequently learned that the surgeons and other hospital personnel were aware of the problem, but chose to continue to perform anthroscopies despite an increased risk for infection.  As Judy noted “In signing the forms authorizing the surgery, I basically consented to a risk without knowing the full extent of that risk.”

Two weeks later she was readmitted with joint infection caused by Staphylococcus aureus, an often aggressive organism that can quickly cause serious tissue damage. as well as sepsis. During the surgery to clean out her knee she suffered an aspiration pneumonia requiring intubation (tube in her trachea) and mechanical respiratory support. She awoke to find her hands and arms tied down with a tube in her throat. This experience haunts her to this day. The pulmonary specialist who cared for her apologized for “everything we did to you.” She was discharged from the hospital with an intravenous line for the delivery of vancomycin that she received for 6 weeks. The good news is the vancomycin eliminated the infection; however, the bad news is she suffered a known complication of vancomycin – tinnitus or ringing of ears. She continues to experience this “high-pitched machine like noise from which there is no escape.”

As Judy notes “I walked into that hospital a perfectly healthy person with a minor problem; and have suffered the consequences of really bad medical decisions, errors, and practices for the rest of my life. That all of these mistakes were preventable haunts me.”

Problem: The hospital failed to discontinue surgery in the face of an outbreak of Staph infections.

Solution: We in health care can learn from Toyota. At their manufacturing plants all frontline assembly workers have a rope called the andon cord that they can pull if they detect a defect in the car they are working on. The assembly line stops until the cause of the defect is clarified and corrected.  Health care providers need to apply the same approach. When an error is detected, in this case a defect in the sterilization of surgical instruments, elective surgery should be discontinued until the cause of the defect is clarified and corrected. If this had happened in Judy’s case she would not have suffered a post-operative infection, pneumonia and permanent ringing in her ears.