1. SURGICAL MISHAPS

Surgery is an area rife with medical errors. However, in a study of 15,000 medical records in hospitals in Colorado and Utah, it was revealed that about 54% of surgical errors are preventable.

The most common surgical mishap reported in the media is “wrong site” surgery, like the man who had the wrong leg amputated. But there are many more mistakes that take place that can be just as devastating. As human beings, it is impossible to totally eliminate the possibility of error, but there are steps that can be taken to raise the bar in providing protection for the patient. This begins with remembering that the surgical team is just that, a team. And every team member is dependent on the others to make certain that the possibility of medical error is minimized.

Pre-operative:

1. If the surgery involves an amputation or removal, make sure that the area is physically marked. Put a red “X” on the side of the body where the surgery is to be performed.
   
2. Confirm the surgery site with the patient before he is anesthetized. Ask the patient why he is in the operating room and if applicable, on which side of the body the operation is to be performed.
3. Ask the patient if he has any allergies-even if the question has already been asked and charted-before beginning anesthesia.
   
4. Perform a verbal run-through with the operating team of all medications to be administered during the surgical procedure.
   
5. Have two members of the surgical team read all labels aloud during the run-through.
   
6. Double check to make sure that any X-rays or other diagnostic images are positioned properly and not turned backward.

Post-operative

1. Make sure an accurate sponge and instrument count is given. If for reasons of patient safety closure happens without a count, take the following steps:
        • Make sure that it is specifically mentioned in the post-operative report
        • As soon as it can be done safely order x-rays to be taken-or other protective        measures-to make certain that no foreign objects were left in the incision
   
2. In certain emergency situations where an accurate account of sponges and instruments is not possible, make a specific note of that fact in the post-operative report.
   
3. Make note of anything unusual in the post-operative report so that the patient can be carefully monitored.
   

Anesthesia

Another surgical area that is intensely vulnerable to medical error is anesthesia.

A patient under general anesthesia is totally dependent upon the surgical team for her welfare, even her survival. Again, it is impossible to
completely eliminate the possibility of mishap, but there are certain
procedures that can be incorporated to help minimize it. These include:

1. Whenever possible, the anesthesiologist should do the pre-op work up.
2. The most efficient monitoring devices available should be employed during the procedure.
3. Both the surgeon and the anesthesiologist should be accessible to the nursing staff during recovery.
   
4. Any unusual patient response to the anesthesia should be clearly noted in the post-operative report.
   

2. Diagnostic Errors: Delayed Diagnosis and Misdiagnosis

Delayed diagnosis takes place when the physician fails to make a timely diagnosis. Delayed diagnosis often occurs because complaints that are symptomatic of serious problems when viewed in the light of certain risk factors are overlooked or dismissed. Misdiagnosis occurs when the wrong diagnosis is made. Diagnostic medical errors include:

• Failure to use a diagnostic test that has been indicated
  
• Failure to act on abnormal test results
  
• Misinterpretation of test results
  
• Misdiagnosis that led to the incorrect treatment

In today’s health care financial structure, it is sometimes difficult to gain access to as many test procedures as one would like, but every appropriate diagnostic technique should be used when making a diagnosis. The physician must become the patient’s advocate when dealing with the health insurer if that is what it takes to avoid medical error.

In certain emergency situations, or in cases where a patient calls into the office with a complaint, it is not possible to perform a full battery of tests. However, there are certain symptoms that should be cause for immediate concern. These include:

• Head injury of any type
  
• Chest or abdominal pain
  
• Fever of unknown origin lasting more than 48 hours
  
• Vaginal bleeding
  
• Convulsion
  
• Cast tightness
  
• Visual alteration
  
• Onset of labor
  
• Numbness

It is also necessary to educate patients so they can act as their own advocates. In private practice, physicians need to get patients actively involved in their own healthcare:

1. Physicians need to ask a new patient with a history of heart disease for a copy of his most recent ECG. This allows a comparative base for future tests.
   
2. Physicians should not rely solely on technology. Patients should be encouraged to practice preventive medicine.
   
3. Women should be urged to perform monthly breast self-examinations in addition to having the appropriate diagnostic tests performed.
   
4. All patients should be made aware of the warning signs of cancer, heart disease and stroke, and of any preventive steps they can take.
   
5. Literature should be displayed in waiting areas that provides important preventive information and “how-to’s.”
   

When a diagnosis is particularly difficult, or there are any doubts, call in a consulting physician. That way extra protection is provided for the patient and the physician. The old adage “there is safety in numbers” holds true in medicine: When two doctors have reached the same conclusion, the chances are that it is the right conclusion and the chance of medical error occurring is greatly reduced.

An emergency situation is rife with the possibility for adverse events and medical error. Whenever feasible contact the patient’s personal physician. Many symptoms, such as chest pain, can be vague and it is extremely helpful to know the patient’s history. Try to determine if the patient has taken any medication prior to coming to the emergency room-and when-in case there are any contraindications between the medication
and the proposed emergency treatment.

3. INCORRECT TREATMENT

Incorrect treatment follows closely on the heels of delayed diagnosis and misdiagnosis as a leading cause of medical error. Certain rules of safety should be followed:

1. Never make any changes in the standard procedures of an advised treatment.
   
2. Monitor the treatment closely, and make sure the patient-and if
   possible the patient’s family-knows how it is supposed to progress.
   
3. Encourage the patient to call with any questions or concerns,
   no matter how minor or inconsequential they may seem.

4. MEDICATION ERRORS

The greatest opportunity for error in the medical field is in the use of medication. Studies report as many as 770,000 people are harmed or killed from Adverse Drug Events (ADE) every year just in hospitals. That does not include the people who are harmed by medication prescribed by their private physician. One study in particular estimated that 9.7 % of ADEs resulted in permanent disability, and the risk of death almost doubles when an ADE occurs. In addition, the length of stay in the hospital rises, as do the costs of the hospitalization. In a study at two hospitals in Massachusetts, ADEs added as much as 4 and 1/2 days to the length of the patient’s hospital stay, and up to $4,600 in unrecoverable costs to the hospital.

One of the great difficulties presented by ADEs is that they are very difficult to predict and no clear cause-and-effect relationship between age, number of drugs prescribed and co-morbidity exists. The one factor that has presented itself on a continuing basis is that ADEs with life-threatening consequences occur more often in ICU patients. However, this could simply be because the patients are already so ill.

It is important to point out that an Adverse Drug Event is not necessarily considered a medical error. According to the IOM, an adverse event is defined as “an injury caused by medical management rather than by the underlying disease or condition of the patient.” For example, if a patient with no known allergies is given a drug and then has a life threatening allergic reaction to it, that is not a medical error. It is also important to remember that, according to the IOM study, hospitals report 7,000 deaths annually due to medical error involving medication error. Therefore this type of medical error must be closely examined.

Preventing Medication Errors
It is the physician’s responsibility to prescribe the best possible medication for a patient, even if that means once again putting up a fight for the patient’s rights. In an instance where a “third party” requirement might preclude prescribing the medication the physician has determined will provide the best treatment, the physician must always opt to make the final decision based on the needs of the patient.

A new patient should be asked to list all current medications she is taking-including over-the-counter drugs and “herbal remedies.”

The popularity of herbal remedies, or food supplements, has mushroomed in the United States. One study estimates that as many as 60 million Americans are taking at least one type of herb, but fewer than 50% report that use to their physicians. This can be a serious problem in light of certain herb-drug interactions that have become evident. For example, a study by NIH found a significant interaction between indinavir, a protease inhibitor used to treat HIV infection, and St. John’s wort (hypericum perforatum) in which concomitant administration of St. John’s wort and indinavir substantially decreased indinavir plasma concentrations.

Another very popular herb, Ginkgo, may interact with anti-coagulant medications like heparin, aspirin and Coumadin and cause the blood to thin too much. This can cause serious bleeding disorders.

The best policy is to make inquiring about the use of herbs and other supplements part of your routine. Include this information in the patient’s medical file, and update it regularly. Advise your patients that before they begin taking any new herbal products, they should call you and make certain there are no currently known interactions between the herb and any medication they might be taking.

When prescribing medication, make the patient aware of any possible side effects, do not assume she will read the printed information the pharmacy provides. Studies have shown that 20% of American adults are functionally illiterate, and that many are very successful in hiding that fact. Do not assume a patient can read and follow printed instructions. Tell the patient precisely how the medication should be taken, and that if she has any type of reaction, or any questions, she should call immediately.

After explaining how to use the medication, make sure to give the patient printed instructions to take with her.

If medication is being administered in the physician’s office, it is best that it be done under the physician’s supervision. That way if the patient does have a reaction, it can be treated quickly. Any physician who administers IM or IV medication in the office should have the following available for emergencies:

• Adrenaline
  
• Oxygen
  
• Injectable diphenhydramine
  

The AHRQ conducted a study at three hospitals in the Northeast to see which medications were most likely to be involved in ADEs. The results were:

• Antibiotics-involved in up to 30%
  
• Analgesics or pain medications-involved in up to 30%
  
• Cardiovascular drugs-involved in up to 18%
  
• Electrolyte concentrates-involved in up to 10%
  
• Sedatives-involved in up to 8%
  
• Antineoplastic drugs-involved in up to 8%
  
• Anticoagulants or blood-thinning drugs-involved in up to 3%

AHRQ studies have indicated that the majority of medication errors occur during ordering and administration. Every physician is warned never to “phone in” prescriptions, and although it is excellent advice, it is nearly impossible to put into practice. Therefore, the person taking the prescription should be asked to repeat it back including spelling out the name of the medication. There are a lot of look alike and sound alike medications, a partial list of which is included in this section. The only way to make certain the right medication will be given to the patient is to have the person dispensing it spell it out.

When writing a prescription, it must be clear and legible. Extra care should be taken when writing out the dosage units and the times that the medication should be taken. Also, blank pre-signed prescription forms should never be left in the office or examining rooms.

The physician must take extreme care when using abbreviations. Misinterpreted abbreviations are a common cause of medication error. The United States Pharmacopoeia (USP) lists the following as “dangerous abbreviations:”

U “unit” can be mistaken for a zero or a four (4) resulting in overdose. Can also be mistaken for “cc” (cubic centimeters) when poorly written.

µg “micrograms” can be mistaken for “mg” (milligrams), resulting in overdose.

Q.D. Latin abbreviation for “every day.” The period after the “Q” has sometimes been mistaken for an “I,” and the drug has been given “QID” (four times daily) rather than daily.

Q.O.D. Latin abbreviation for “every other day.” Misinterpreted as “QD” (daily) or “QID” (four times daily). If the “O” is poorly written, it looks like a period or “I.”

SC or SQ “Subcutaneous” can be mistaken as “SL” (sublingual) when poorly written.

TIW “Three times a week” can be misinterpreted as “three times a day” or “twice a week.”

D/C “Discharge” also “discontinue.” Medications have been prematurely discontinued when D/C (intended to mean “discharge”) was misinterpreted as “discontinue” because it was followed by a list of drugs.

HS “Half strength” can be misinterpreted as the Latin abbreviation

“HS” (hour of sleep).

cc “Cubic centimeters” can be mistaken as “U” (units) when poorly written.

AU, AS, AD Latin abbreviations for “both ears,” “left ear,” “right ear” can be misinterpreted as the Latin abbreviation “OU” (both eyes), “OS” (left eye), “OD” (right eye).
Most important of all, do not deviate from the recommended dosage of a medication unless it is indicated-and fully documented.

5. OBSTETRICAL MISHAPS

The good thing about Obstetrical medicine is that it usually follows an orderly routine-the patient sees the doctor in the doctor’s office until it is time for delivery, then she is admitted to a hospital or birthing facility.

There are some very obvious steps to help prevent medical error or adverse events during the pregnancy and office visit stage, beginning with patient education. The pregnant patient should be given information about:

• The importance of proper nutrition
  
• The importance of proper exercise
  
• The potential harm in the use of drugs, alcohol and cigarettes
  
• The potential harm in the use of over-the-counter medications

It is not enough to just tell the patient. Materials should be provided to read on the topic, or videos to watch. Make her proactive in protecting herself and her baby during her pregnancy.

In a large practice, a specific team needs to be assigned to each patient, so the same staff members interact with the patient throughout the pregnancy. That way the staff becomes familiar with the patient, and the patient becomes comfortable with the staff and is more inclined to ask questions or report any discomfort or unusual symptoms she might be having. Again, this helps safeguard the patient and the baby.

Once it is time for delivery, teamwork begins in earnest. Ideally it should be a small team, with the physician as team leader. The team shares responsibility for the patient and for all decisions regarding care. Efficient, reliable team coordination and communication is critical.

Whenever possible, the team members should remain constant. This allows the team to maintain structure, and to better develop and implement group planning and problem solving.

Once the baby is born, close attention must be paid to patients exhibiting symptoms, or reporting complaints of postpartum depression. Do not hesitate to refer the patient to a mental health specialist. Once again, this might require the physician to take on the role of patient advocate. Not to do so can have tragic consequences in the life of both mother and child.

6. EQUIPMENT MALFUNCTION/MISUSE

As medicine has entered the age of technology, health care professionals
are forced to rely more and more on equipment for many reasons:

• To diagnose
  
• To provide treatment
  
• To monitor the patient
  
• To administer medication

Each of these uses of technology creates situations that are extremely vulnerable to medical error.

To diagnose
It is important to be certain that any high-tech equipment used in making diagnoses is functioning properly and that all standards for maintenance are observed. It is equally important to make certain that “low-tech” equipment is also functioning properly. A tool as simple as the autoclave is critically important because it is used to sterilize equipment that is used on all patients. If it is not maintaining the proper temperature, the equipment might not be properly sterilized and that can lead to putting patients at risk. Make routine periodic checks of all equipment to make sure that it is operating at optimum levels.

To provide treatment
There probably is no medical specialty that does not use equipment to provide treatment. From providing radiation therapy in oncology, to removing skin cancer in dermatology, equipment is everywhere. The rules are very simple:

• Make sure the equipment is properly calibrated
  
• Make sure the environment in which the
  treatment is provided is safe
  
• Make sure the physician, nurse or technician
  operating the equipment is properly trained

To monitor the patient
Not too many years ago, the only “monitoring” equipment was found in the ICU. That is no longer true. There are now home monitoring devices patients use to monitor everything from their blood pressure to their blood sugar levels.

In addition to following all the aforementioned rules about equipment maintenance and training, when it comes to home monitoring devices health care professionals must add a crucial step-patient training

It is extremely important that any patient using a home monitoring device understand how it should work, and how to recognize if it is not working properly. The patient’s family and/or caregivers should also be fully trained. In addition, the physician who is in charge of giving the patient the monitoring device should make certain that someone from his/her office or facility routinely follows-up on all monitored patients to make certain they are following the rules regarding utilization and maintenance.

Another form of “patient monitoring” that is rapidly coming to the fore is the implant. Heart pacemakers have been in use for many years, and have become extremely reliable. As technology has advanced, many patients now have access to “phone in” maintenance so they can regularly check their pacemakers and be assured they are working properly.

One of the most exciting advances in the field of implants is the heart defibrillator. This device came to the public’s attention when Vice President Dick Cheney had one implanted.

This device has an amazing track record in studies. In fact, it performed so well that in a test group of high-risk patients who had heart attacks, the mortality rate was reduced by more than half. Experts estimate that there are currently 500,000 people in the U.S. who have had heart attacks in the past that can benefit from the defibrillator, and that there will be approximately 80,000 new heart attack survivors each year who will be candidates for the implant.

The biggest safety risk of implants is the danger of malfunction, and occasional recalls. For this reason, the following steps must be taken when an implant is used:

• Give the patient written information regarding the manufacturer of the implant, plus the model and serial number of the specific device implanted
  
• Give the patient written information about how to subscribe to continuing information about the device
  
• Make certain the patient understands how the implant should function
  
• Make certain the patient is aware of signs and symptoms that the implant might not be functioning properly
  

To treat the patient
All equipment-from the IV to the thermometer-must be routinely checked to make sure it is functioning correctly. After an IV is started, it should be checked within just a few minutes to make sure it is properly adjusted, then it should be rechecked every half-hour to make sure it stays properly adjusted.

Only professionals with complete training should use high-tech equipment, like the laser. In addition, the equipment must be properly maintained. Anyone using high-tech devices to treat patients should understand the following:

• How the equipment is supposed to work
  
• How to tell if it is not working properly
  
• How to tell if the patient is having an adverse reaction to the treatment
  

A patient’s comments regarding pain must not be dismissed as nerves, or cowardice. Treatment should be stopped immediately so the equipment can be checked to make sure it is functioning properly. Far better to have to reschedule an appointment than risk making a mistake that could harm the patient.

Before using any new devices, everyone who will be using them to treat patients must be fully trained and tested to make sure they understood their training.

7. SYSTEM ERRORS

In its report, the IOM stressed that most medical errors are system errors-in other words, errors in the way care is delivered.

In a major study supported by the AHRQ, it was discovered that in more than 75% of adverse drug events the root of the problem was failure at the system level.

Facility-based Systems
Staffing levels have been shown to be a major element in system failure. One study showed that adequate nursing levels had a major impact on
certain post-surgical medical errors such as pulmonary compromise.

If the failures in the system can be corrected, medical errors can be greatly reduced. Two examples of this are:

• A study conducted in 1999 showed that including a pharmacist on medical rounds reduced medication errors by almost two-thirds
  
• The use of standardized guidelines and protocols, and standardizing equipment reduced the rate of medical errors in anesthesia from 25.50 patients per million, to 5.4 patients per million, a reduction of more than 70%
  

Advances in technology have also enabled giant steps forward in reducing systems errors. Research is now taking place in which a computer is used to monitor the patient and make note of the following:

• Changes and/or fluctuations in heart rate
  
• Changes and/or fluctuations in respiratory rate
  
• Changes in mental state
  
• Seizure
  
• Fever
  
• Anaphylaxis
  
• Diarrhea
  
• Rash

If any of these symptoms occur, the computer alerts the hospital staff. The computer will also alert the staff if any signs of a possible ADE occur, such as:

• High or low blood levels of certain medications
  
• Inappropriate medication dosage
  

The computer system can be linked to the pharmacy, lab and treatment facility so physicians can be notified immediately of any drug allergies or food and/or drug contraindications.

Until that technology is perfected and made widely available, it remains incumbent on human systems to prevent medical errors. To begin with:

1. When a drug is repackaged, it should be double-checked by a different staff member before being made available for use.
   
2. Repackaged drugs should be clearly and correctly labeled. A different staff member should check the label information before the drug is made available for use.
   
3. If a notation in a chart or a patient’s medical record is not understandable, help should be sought. It does not matter if the problem is illegible handwriting, or an abbreviation or shorthand with which the health care provider is not familiar. This may seem insignificant on its face, but it is extremely important.
   

Office-based Systems
Here again there are computer programs and high-tech equipment in development that will assist with routine tasks and greatly reduce the possibility of medical error, but until they become widely available, “low-tech” human systems must assume the burden of safety.

A critical factor in creating system-wide processes is to make sure that everyone who is part of the system is aware and involved. And everyone means exactly that, in both a facility and private practice. That extends to all support personnel, including the janitorial staff. If the janitor finds something on the floor, he/she should not assume it is trash and just throw it away. There needs to be a designated area where questionable papers/items can be deposited until they can be checked by one of the administrative staff.

No one should ever answer questions outside his/her area of expertise. That includes physicians and nurses.

There needs to be a checklist of “things to remember” when dealing with a new patient. This list can include:

1. 1. Don’t assume the patient can read and/or understand written instructions.
   
2. Even though a patient who speaks with an accent may have excellent verbal skills, don’t assume he/she can read and understand English medical instructions.
   
3. If someone accompanies an elderly patient, ask if the patient would like to have the other person present during discussions.
   
4. Ask the patient to bring all current medications, including over-the-counter drugs and herbal remedies. Not just a list, but the actual containers.
   
5. Ask the patient about allergies, even if medical records have been received from other physicians.
   
6. Ask the patient about any adverse drug reactions he may have had, even if that is recorded in existing medical records.
   
7. Ask questions and get the patient’s feedback to determine whether or not everything you have said has been understood. If you do not think it has, repeat the information in a different way, and then once again get the patient’s feedback. If the patient still does not seem to understand, ask if there is someone with the patient, or someone you can call, to make sure all instructions are followed. You might risk insulting the patient, but hurt feelings are a much better alternative than medical error.

The Importance of Risk Factors
Keep a list of each patient’s risk factors for heart disease, cancer and diabetes prominently displayed in the patient’s chart. Make sure that each new patient gives a detailed report of any risk factors arising from current habits or physical factors-such as smoking, or being obese-as well as those arising from family history. Knowing risk factors is critically important in helping prevent delayed diagnosis. An example is a young woman who presents with vague abdominal pain. If she is at risk for ovarian cancer, order a CA 125 antigen blood test.

In patients with diabetes, an aggressive management approach must be undertaken. Every time a diabetic patient comes to the office, check his feet. In the appendix you will find a Diabetes Management Flow Chart. Maintaining such a chart can greatly reduce the risk of delayed diagnosis of complications of diabetes.

Recent changes in the early warning signs of heart attack show marked differences between men and women. Make literature available to your patients, especially your female patients, so they recognize these symptoms.

If a patient seems to be depressed, have him/her complete the Center for Epidemiologic Studies (CES) of the National Institute of Mental Health Self-Report Depression Scale, which can be found in the Appendix.

Stay up-to-date on all changes relating to risk factors for major diseases. Know when to perform certain health screening functions.

Internal Communication
Don’t give verbal orders to your staff, write them. This accomplishes two important risk-reduction goals:

1. It forces you to take your time which will increase accuracy,
   
2. It eliminates both you and your staff having to rely on memory.
   

Even when phoning in a prescription, write it out first.

Create a working atmosphere in which all personnel feel comfortable in reporting mishaps or errors.

The Importance of Personal Diligence
Just as every member of the staff of a facility and private practice must be part of system-wide diligence, each must also be personally vigilant. All personnel should be trained to identify certain signs and behaviors in patients and report them to the appropriate medical professional. Some examples:

1. If a nurse assistant goes in to change a bed and notices that the patient seems to have labored breathing, or is disoriented, the nurse should be notified.
   
2. If an orderly is in a patient room and notices that an IV has stopped, or that a monitor is not working, the nurse should be notified.
   
3. If the person admitting a patient notices that the patient seems disoriented and/or does not understand the questions being asked, a supervisor or medical staff member should be notified.
   
4. If support personnel working in the admitting area, or in a waiting area, notice that a waiting patient seems disoriented, or has fallen asleep and can’t be awakened, medical personnel should be notified immediately.
   

Health care professionals must not forget the final, most important link in the health care chain-the patient. Patient education cannot be over emphasized. Patients must be fully informed about every aspect of their healthcare:

• Diagnosis
  
• Medication
  
• Treatment
  

If surgery is necessary, the pre-op discussions must be thorough. Exactly what will happen, how long it will take, how the patient can expect to feel following the surgery, must be explained.

Patients must be advised to tell the medical personnel in the operating room why they are there, what operation they are supposed to have, etc. If the patient has not had an in-person consultation with the anesthesiologist, they must be directed to inform the anesthesiologist of any allergies or adverse drug reactions he/she has ever experienced-just in case.

Patients should be made to feel comfortable asking questions, asking for clarification, asking for more information.

Patients must be educated to know that it is critical for them to share in the responsibility for their health care and their well being.

The Quality Interagency Coordination Task Force (QuIC) is a group of Federal agencies in partnership with public and private sector groups working together to help make the health care system safer. The QuIC prepared a document for distribution to patients: 20 Tips to Help Prevent Medical Errors. A copy of this document that can be reproduced as a hand-out for patients is in the Appendix, or you can be prepare one that is better suited to your specific medical specialty. Following are 5 items from the complete list:

1. Speak up if you have questions or concerns. Choose a doctor who you feel comfortable about talking to about your health and treatment. Take a relative or friend with you if this will help you ask questions and understand the answers. It is okay to ask questions and to expect answers you can understand.
   
2. Keep a list of all the medicines you take. Tell your doctor and pharmacist about the medicines that you take, including over-the-counter medicines such as aspirin, ibuprofen, and dietary supplements like vitamins and herbal remedies. Tell them about any drug allergies you have. Ask the pharmacist about side effects and what foods or other things to avoid while taking the medicine. When you get your medicine, read the label, including warnings. Make sure it is what your doctor ordered, and you know how to use it. If the medicine looks different than you expected, ask the pharmacist about it.
   
3. Make sure you get the results of any test or procedure. Ask your doctor or nurse when and how you will get the results of tests or procedures. If you do not get them when expected-in person, on the phone, or in the mail-do not assume the results are fine. Call your doctor and ask for them. Ask what the results mean for your care.
   
4. Talk with your doctor and health care team about your options if you need hospital care. If you have more than one hospital to choose from, ask your doctor which one has the best care and results for your condition. Hospitals do a good job of treating a wide range of problems. However, for some procedures (such as heart bypass surgery), research shows results often are better at hospitals doing a lot of these procedures. Also, before you leave the hospital, be sure to ask about follow-up care, and be sure you understand the instructions.
   
5. Make sure you understand what will happen if you need surgery. Ask your doctor and surgeon:
        
        • Who will take charge of my care while I’m in the hospital?
        • Exactly what will you be doing?
        • How long will it take?
        • What will happen after the surgery?
        • How can I expect to feel during recovery?
   

Tell the surgeon, anesthesiologist, and nurses if you have allergies or have ever had a bad reaction to anesthesia. Make sure you, your doctor, and your surgeon all agree on exactly what will be done during the operation.