Posted by: Knightbird | October 25, 2010


When I was in college back in the 1970’s, I had a classmate considering Anesthesiology as a career choice. At that time, it was a very risky profession with climbing malpractice rates and an extremely high death rate. In 1982, a 20/20 News Program discussed anesthesia related deaths. Twenty five years ago (1985), the profession saw one death for every 5,000 cases. Rather than join the bandwagon of physicians who wanted their state legislatures and Congress to pursue “Tort Reform,” the Anesthesiologists chose a different path, to respect their patients and move to reform how they practiced Anesthesiology. Their record is one of incredible success, as reported in the Wall Street Journal. [i]

Instead of choosing to blame the patient for suing for poor results, the Anesthesiology profession choose to fix their problems, a novel approach at the time. Dr. Ellison C. “Jeep” Pierce Jr. lead the initiative. [ii] The results are astounding.

The collection of data was pivotal to their results (surprise, surprise). By collecting data, they were able to analyze why deaths occurred. One major cause of death was “intubation errors.” The Anesthesiologist would insert the tube into the stomach. When the patient turned blue of their blood turned dark, it was too late to save the patient. [iii] Deaths from this cause have all but eliminated through the use of pulse oximetry and capnography. Other solutions have been adopted that further reduce claims. In 1972, when my classmate was considering Anesthesiology, the profession accounted for 7.9% of all medical claims. Since then, both the number of, and the dollar value of, claims have declined substantially. In 2005, according to the Wall Street Journal article, the rate of death has declined 40 fold, from the 1 in 5,000 cases to 1 in 200,000 to 300,000 cases.

Anesthesiologists also use a checklist to ensure that they are don’t forget crucial steps for patient safety. Lean Healthcare practitioners have managed to emulate the success of the Anesthesiologists by focusing on systems, but the medical profession as a whole have not. Until profession wide efforts are adopted, we have to depend on individual hospitals to develop the passion for patient safety that Lean Healthcare provides. Spread the fire.

[i] “Once Seen as Risky, One Group Of Doctors Changes Its Ways,” The Wall Street Journal, June 21, 2005.

[ii] Joseph T. Hallinan, Why We Make Mistakes, Broadway Books: New York (2009), pp. 5-7



  1. Thanks for sharing the links and the data. I read the “Why We Make Mistakes” book last year and really enjoyed it – very informative and interesting reading.

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