Famed neurosurgeon's century-old notes reveal 'modern' style admission of medical error

February 21, 2011, Johns Hopkins Medical Institutions

The current focus on medical errors isn't quite as new as it seems. A Johns Hopkins review of groundbreaking neurosurgeon Harvey Cushing's notes, made at the turn of the last century, has turned up copious documentation of his own surgical mishaps as well as his suggestions for preventing those mistakes in the future.

Authors of the article, published in the Feb. , suggest that such open documentation may have played an important role in spurring groundbreaking advances in Cushing's era — and could have the same effect today.

"Acknowledging medical errors is evidently something that doctors identified early on as critical to advancement a very long time ago," says principal author Katherine Latimer, B.S., a medical student at the Johns Hopkins University School of Medicine.

Latimer and her colleagues scoured Johns Hopkins' archives to locate operative notes covering 878 of Cushing's patients. The notes, transferred decades ago to microfilm, covered the early years of Cushing's career, from 1896 to 1912, at The Johns Hopkins Hospital. After deciphering the notes—a monumental task, the authors say, owing to Cushing's poor handwriting, abbreviations, and pages crowded with notes of other physicians, too—the researchers selected 30 cases in which errors were clearly delineated.

The cases fell into categories of errors similar to those that plague doctors today, the authors said, classifying 11 of the cases as errors of judgment in which Cushing made the wrong choice during a surgery. One example: operating on the wrong side of a patient's brain. Seventeen cases were identified as "human error," mistakes in which Cushing revealed clumsy or careless behavior, such as dropping an instrument into a surgical wound. Three of the errors were considered equipment or tool oversights, such as the case in which a woman's heavy bleeding left Cushing and his colleagues without enough wax, a substance used at the time to seal blood vessels.

Latimer and her colleagues say they were surprised by Cushing's frank and copious documentation of his own shortcomings. His notes acknowledged mistakes that may have resulted in patients' deaths, as well as those that didn't seem to harm patients' outcomes. They said the documentation took place in an era in which malpractice litigation was becoming a growing concern for doctors. Though malpractice penalties were substantially smaller in Cushing's day, lawsuits presented a serious risk for physicians' reputations, the authors noted.

The authors also emphasized that Cushing practiced in a time of enormous surgical innovation. For example, patient mortality from surgical treatment of brain tumors fell from 50 percent to 13 percent during his career. While some of this jump ahead was due to improving technology, the authors propose that part of the reason was open documentation of errors, which helped Cushing and other surgeons develop fixes to avoid them.

"People are human and will make medical mistakes," says Latimer, "but being vigilant about your own shortcomings is critical to improving. To keep medical innovation flowing, we need to strive to maintain this same vigilance today."

Alfredo Quinones, M.D., associate professor of neurosurgery at the Johns Hopkins University School of Medicine and senior author of the study, adds that today's continue to have a tremendous impact on patients and their families. "Recognizing errors and reporting them can help us greatly improve medicine," he says. "After all, we are all working towards the same goal: better patient care."

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