When things go wrong: protecting patients and supporting doctors

A healthcare system should ensure that surgical errors are kept to a minimum, and if possible are avoided altogether. Unfortunately, errors do occur however carefully one tries to avoid them. Once recognized an error must be rectified as soon as possible. An appropriate apology to the patient or their relative is an absolute requirement. In this article I review the processes available to deal with errors both locally and through the regulatory authorities if considered necessary. I look at how lapses, both clinical and non-clinical, are handled locally and by the appropriate regulatory body. I also discuss how allegations relating to fitness to practise are investigated. Whilst the over-riding responsibility of all these structures is to protect patients, as mentioned it is necessary also to support doctors and to learn the lessons on how and why the errors have occurred. The maintenance of professionalism is essential. As well as supporting and protecting the patient, support for the surgeon in the workplace is a necessary requirement.     

Lest we forget the surgeon

Within the United States, the applications from medical graduates to general surgery residency programs declined by 30% since 1992, and it has been estimated that by 2005 only 5% of US medical graduates will opt for a professional career in surgery. Thus in the assessment of the projected needs for surgical practice for the new century, we must not overlook the surgical manpower issue. We have to ensure that the high-tech operating rooms of the future will be manned by surgeons with the right personality, attitudes, competence, and skills. Certain key issue have to be addressed if we are to achieve this essential objective. These include changes in health care systems, including the rapidly advancing technologically-dependent minimal access therapy procedures, changes in attitude and culture between doctors and patients, especially in relation to human error enacted during health care delivery with the abolition of the "shame and blame culture," changes in the selection and training of surgeons that have to take into account the reduced working week for residents, and appraisal systems that will ensure sustained competence of fully trained surgeons throughout their professional life. Since it is not possible to eliminate errors completely from clinical practice, we can improve the quality of medical and surgical care by adopting error-tolerant operating medical systems based on progress in cognitive psychology, human factors, and human reliability assessment. Error-tolerant operating medical systems should enable detection, reporting, and targeted reduction of errors.     

Identifying error pathways during elbow and knee replacements

The aim of our study was to identify errors and error pathways during joint replacements and to propose improvements. A time-action and error analysis method was adapted for use during surgery. The error analysis consisted of identifying all possible errors, determining error paths presented in an error chart, quantifying errors, and determining the impact of errors. This method was used to evaluate joint replacements. We evaluated five knee and 11 elbow replacements done by two experienced surgeons. The main error for elbow replacements was caused by inadequate instruments. The main error for knee replacements was caused by inexperienced nurses being unfamiliar with guiding instruments. The time-action analysis showed a large variation in procedure duration. The main surgical limitations for both procedures were waiting caused by the cementing process and waiting caused by inexperienced scrub nurses. Our study identified errors and surgical limitations during joint replacements by using time-action and error analysis. Placement of both prostheses will benefit from new fixation techniques, a more experienced nursing staff, and more organized instrument tables.     

Safe surgery,the human factors approach

Studies estimate that a degree of error occurs in 5–15% of all hospital admissions, with 45% of errors occurring in the operating theatre. Staffing limitations, high turnover rates, site and side-specific surgical procedures, make operating theatres a high-risk environment. Valuable lessons may be learned from the aviation experience with error management. With over 70% of air-crashes occurring due to human rather than technical error, the Human Factors Approach to error recognises the potential for errors occurring due to human limitations, such as stress and fatigue. It encourages error reporting in a non-punitive environment, where it is seen as a valuable source of information, facilitating education and future error prevention. Errors in healthcare and surgery however, have been traditionally associated with secrecy and embarrassment, often reaching an unsatisfactory endpoint with no resultant education. Application of the Human Factors Approach to error management in healthcare, can only serve to improve safety standards in our hospitals and satisfy ever-increasing public expectations.     

Ethical Issues in Surgical Innovation

Innovation is responsible for most advances in the field of surgery. Innovative approaches to solving clinical problems have significantly decreased morbidity and mortality for many surgical procedures, and have led to improved patient outcomes. While innovation is motivated by the surgeon’s expectation that the new approach will be beneficial to patients, not all innovations are successful or result in improved patient care. The ethical dilemma of surgical innovation lies in the uncertainty of whether a particular innovation will prove to be a “good thing.” This uncertainty creates challenges for surgeons, patients, and the healthcare system. By its very nature, innovation introduces a potential risk to patient safety, a risk that may not be fully known, and it simultaneously fosters an optimism bias. These factors increase the complexity of informed consent and shared decision making for the surgeon and the patient. Innovative procedures and their associated technology raise issues of cost and resource distribution in the contemporary, financially conscious, healthcare environment. Surgeons and institutions must identify and address conflicts of interest created by the development and application of an innovation, always preserving the best interest of the patient above the academic or financial rewards of success. Potential strategies to address the challenges inherent in surgical innovation include collecting and reporting objective outcomes data, enhancing the informed consent process, and adhering to the principles of disclosure and professionalism. As surgeons, we must encourage creativity and innovation while maintaining our ethical awareness and responsibility to patients.     

Unintentional side error for continuous sciatic nerve block at the popliteal fossa

Among all fields of healthcare about 45% of medical errors occur in the operating theatre. Wrong site procedures remain one of the most preventable medical errors. Unintentional wrong-sided peripheral nerve block is relatively a rare event in anesthesia care. However, the incidence is unknown but each time wrong-sided block occurs it represents a mistake and a potential for harm. The surgical safety checklist was established in 2008 by the world Health organization (WHO) as a part of the "Safe surgery save Lives" initiative. We report in this article a case of wrong sided continuous popliteal sciatic nerve block and discuss the role of the WHO's checklist in preventing wrong side peripheral nerve block and surgery.     

Laparoscopic needles and trocars: an overview of designs and complications.

Although the gynecologist has utilized the laparoscope both diagnostically and therapeutically for several decades, laparoscopic surgery has only recently gained great acceptance in the general surgical and urologic community. However, the enthusiasm for this new technology for minimally invasive surgery must be dampened by the small incidence of complications, most of which occur during the creation of the initial pneumoperitoneum and, in particular, during the insertion of the Veress needle and the principal trocar. The purpose of this paper is to review needle and trocar designs, to describe the complications of their use, and to identify factors that may contribute to injury and those that will minimize the risk.     

The retained surgical specimen, an unappreciated retained foreign object

A retained foreign object is a preventable surgical error and has typically been considered a surgical instrument, needle, or sponge. A new retained surgical object is a retained surgical specimen (RSS). This case study outlines the nature of the RSS, the paradigm shift that has led to this becoming a new healthcare error, and steps to prevent this new type of retained object from occurring.     

Cerebral hyperthermia and cardiac surgery: consequences and prevention

Temperature management during cardiac surgery deserves considerable attention because it has broad effects, altering virtually every physiologic process, including oxygen demand, blood flow, cardiac output, and coagulation. Temperature is also important in cardiac surgery because virtually all patients undergo significant temperature change. These changes can be unique in mammalian physiology both with regard to their magnitude and rate of change. Furthermore, cardiac surgical patients may be uniquely vulnerable to the effects of temperature. Because of vascular disease and embolization, many patients are at risk for cerebral ischemia. Additionally, their cardiac, pulmonary, and renal reserve is typically limited; and there is risk for perioperative bleeding. Patient temperature can affect all of these processes and has its greatest effect on those who are physiologically most fragile. An appreciation for temperature management is also compelling because, unlike new technologies, procedures, or drugs; temperature management is simple, practical, applicable to every patient, and can be performed with very little cost. This article will show why cerebral hyperthermia should be avoided in cardiac surgery. Second, it will discuss why it occurs and the management steps that may prevent it. Finally, we will highlight recent discussion of postoperative hyperthermia and speculate as to its origin and relevance.     

Improving disclosure and management of medical error – An opportunity to transform the surgeons of tomorrow

IntroductionHuman error is the major causal factor of industrial and transportation accidents and healthcare is not immune to the effects of human error. Medical error can be defined as the failure of the planned action to be completed as intended or the use of a wrong plan to achieve an aim.AimThe objective of this literature review was to explore the practices of medical error management and disclosure by surgical trainees and to examine how to better prepare and educate the surgeons of tomorrow.MethodsPubMed was searched to identify available literature. Preliminary search criteria included medical error and junior doctors, management and prevention of medical error.ResultsFifty-two papers were included for review. Medical error is common and junior doctors are more vulnerable to err. Most serious errors occur in the emergency department, operating rooms and the intensive care unit. Improvements in patient safety result primarily from organizational and individual learning, particularly with reference to trainee doctors who present an enhanced level of risk.ConclusionJunior doctors are a unique population, with a higher propensity to medical error. A transition from the current culture of ‘name, blame and shame’ is required. We need to ensure that the ‘learning moment’ is seized and that mistakes are learned from and not simply forgotten. Surgery has an opportunity to learn from high risk-industries and incorporate human factors training, into surgical training programs in order to better manage and prevent medical error.     

Assessment of the emergency surgical patient

It is well known that emergency surgical patients have a higher risk of postoperative morbidity and mortality than those having elective procedures. A systematic preoperative assessment forms an important part of identifying risk factors and reducing their impact. Patients may require simultaneous resuscitation and assessment. Further deterioration in the patient's condition must not occur as a result of delays in decision making or awaiting results of investigations. A risk assessment score is useful for both surgeons and patients to provide information on possible postoperative outcomes. It will aid discussion for informed consent and guide planning of staffing for surgery and postoperative care location.     

Assessment of the emergency surgical patient

It is well known that emergency surgical patients have a higher risk of postoperative morbidity and mortality than those having elective procedures. A systematic preoperative assessment forms an important part of identifying risk factors and reducing their impact. Patients may require simultaneous resuscitation and assessment. Further deterioration in the patient’s condition must not occur as a result of delays in decision making or awaiting results of investigations. A risk assessment score is useful for both surgeons and patients to provide information on possible postoperative outcomes. It will aid discussion for informed consent and guide planning of staffing for surgery and postoperative care location.     

Patient safety in end-stage renal disease: How do we create a safe environment?

The Institute of Medicine estimated that 44,000 to 98,000 hospitalized patients die annually as a direct result of preventable medical errors. Errors occur because competent practitioners are human, and the systems we design are imperfect. Improving patient safety requires acknowledging medical errors, encouraging the reporting of errors, and improving systems to reduce the likelihood of future errors. Several challenges must be addressed to accomplish this goal. The definition of medical errors must be widely agreed on and accepted. Adverse outcomes are often the result of multiple systems failures. Therefore systems analysis, not blaming an individual, should be the focus of error reduction. A "culture of safety" should be created, which encourages reporting errors and "near-misses." An effective reporting system has 2 components, one for public accountability for errors that result in serious injury and another for confidential reporting of mistakes that have the potential for serious injury. Regulatory protection from discovery must be established for voluntary error and near-miss reporting systems. In the nephrology community, novel uses of technology should be sought to prevent errors, human factors leading to errors should be identified and anticipated, and patterns of interaction at the machine-human interface should be studied. Progress in improving patient safety has occurred in some areas, such as pharmacy services. Such known and tested patient safety practices should be deployed in dialysis facilities. Success in improving patient safety will require leadership, collaborative efforts among the many stakeholders in the ESRD program, and adequate allocation of resources.     

Laser surgery for benign laryngeal disease. Conservation and ergonomics

In surgery, the era of tissue conservation and advanced engineering ergonomics has arrived. As a surgical tool, lasers will undergo extensive development. The most precise of surgical tools, its ability to focus to spots equal to its wavelength will permit intracellular surgery. A new technology must be mastered by the operator, who must have a solid foundation in laser physics. The small spot size possible with the new laser laryngoscopy coupler introduces one more refinement in the growing trend toward "conservational" surgery of the larynx for both benign and malignant laryngeal disease.     

Medication safety in pediatric anesthesia: An educational review and a call to action

Children presenting for anesthesia are at high risk for medication error during their care. In this educational review, we address the rates of medication error in pediatric patients undergoing anesthesia, why they are at higher risk than adults, and why reporting chronically underestimates the number of medication errors incurred during the anesthetic care of children. We also introduce the Anesthesia Patient Safety Foundation and Wake Up Safe, two safety organizations that have led the call to decrease medication errors. We discuss various tools to increase medication safety, as championed by Anesthesia Patient Safety Foundation and Wake Up Safe, including human factors research and highlight a few studies that have evaluated and addressed medication safety in the anesthesia environment.     

Confounding: what it is and how to deal with it

As confounding obscures the 'real' effect of an exposure on outcome, investigators performing etiological studies do their utmost best to prevent or control confounding. Unfortunately, in this process, errors are frequently made. This paper explains that to be a potential confounder, a variable needs to satisfy all three of the following criteria: (1) it must have an association with the disease, that is, it should be a risk factor for the disease; (2) it must be associated with the exposure, that is, it must be unequally distributed between exposure groups; and (3) it must not be an effect of the exposure; this also means that it may not be part of the causal pathway. In addition, a number of different techniques are described that may be applied to prevent or control for confounding: randomization, restriction, matching, and stratification. Finally, a number of examples outline commonly made errors, most of which result from 'overadjustment' for variables that do not satisfy the criteria for potential confounders. Such an example of an error frequently occurring in the literature is the incorrect adjustment for blood pressure while studying the relationship between body mass index and the development of end-stage renal disease. Such errors will introduce new bias instead of preventing it.     

The relationship between surgeon and basic scientist

Basic science research has always been the cornerstone of a solid academic career, even for surgeons. In the past, many cardiothoracic and cardiovascular surgeons have used the large animal laboratory to design surgical operations, refine extracorporeal circulation, improve myocardial protection or simply validate clinical concepts. Today, funding for large animal research has almost disappeared. The basic science areas of 'cellular, molecular, genomics or gene therapy' must be involved to be considered for national or even local funding. This endeavor requires a new generation of surgical scientists and perhaps even more importantly, a new environment for the performance of such research. Academic surgery does not exist without active and long-standing commitment to research. Clinical research focusing on patient outcome remains an important task of the academic surgeon but this paper will focus on the relationship between surgeons and basic scientists and shall concentrate primarily on translational research and its challenge now and in the future. The collaboration between basic scientist and clinician is more essential than ever, because the society still optimally rewards science that has potential clinical applicability [1]. Even within surgical departments, active support and very close contact with PhDs can be essential for the clinical faculty members to be productive, using cellular and molecular techniques. In cardiovascular medicine and biology, there is a great potential to prevent or treat diseases with these techniques. The potential to modify ischemia-reperfusion, inflammation, angiogenesis, restenosis, organ tolerance or cardiomyocyte transplantation to remodel ventricles will be accomplished by a better understanding of cardiovascular biology. Surgeons must plan for a speciality that may look quite different in the next future.     

Complications after carotid endarterectomy are related to surgical errors in less than one-fifth of cases. Swedvasc--The Swedish Vascular Registry and The Quality Committee for Carotid Artery Surgery.

OBJECTIVES: to study possible relations between indications, contraindications and surgical technique and stroke and/or death within 30 days of carotid endarterectomy (CEA). DESIGN: analysis of hospital records for patients identified in a national vascular registry. METHOD: during 1995-1996, 1518 patients were reported to the Swedish Vascular Registry - Swedvasc. Among these the sixty-five with a stroke and/or death within 30 days were selected for study. Complete surgical records were reviewed by three approved reviewers using predetermined criteria for indications and possible errors. RESULTS: an error of surgical technique or postoperative management was found in eleven patients (17%). In six cases (9%) the indication was inappropriate or there was an obvious contraindication. The indication was questionable in fourteen (21.5%). Half of the patients (52.5%) had surgery for an appropriate indication, and no contraindication or error in surgical technique or management was identified. CONCLUSION: more than half the complications of CEA represent the "method cost", i.e. the indication, risk and surgical technique were correct. However, the stroke and/or death rate might be reduced if all operations conformed to agreed criteria.     

Normal accidents: human error and medical equipment design

High-risk systems, which are typical of our technologically complex era, include not just nuclear power plants but also hospitals, anesthesia systems, and the practice of medicine and perfusion. In high-risk systems, no matter how effective safety devices are, some types of accidents are inevitable because the system's complexity leads to multiple and unexpected interactions. It is important for healthcare providers to apply a risk assessment and management process to decisions involving new equipment and procedures or staffing matters in order to minimize the residual risks of latent errors, which are amenable to correction because of the large window of opportunity for their detection. This article provides an introduction to basic risk management and error theory principles and examines ways in which they can be applied to reduce and mitigate the inevitable human errors that accompany high-risk systems. The article also discusses "human factor engineering" (HFE), the process which is used to design equipment/ human interfaces in order to mitigate design errors. The HFE process involves interaction between designers and endusers to produce a series of continuous refinements that are incorporated into the final product. The article also examines common design problems encountered in the operating room that may predispose operators to commit errors resulting in harm to the patient. While recognizing that errors and accidents are unavoidable, organizations that function within a high-risk system must adopt a "safety culture" that anticipates problems and acts aggressively through an anonymous, "blameless" reporting mechanism to resolve them. We must continuously examine and improve the design of equipment and procedures, personnel, supplies and materials, and the environment in which we work to reduce error and minimize its effects. Healthcare providers must take a leading role in the day-to-day management of the "Perioperative System" and be a role model in promoting a culture of safety in their organizations.     

Opportunity

Opportunities abound in all we see and do. We must view life as filled with opportunities if we are to take advantage of all that life has to offer. The future of surgery and the monetarization of healthcare may seem grim to some, but to those who see the opportunities in these changes and prepare for the evolution in surgical practice through education and discipline will go the leadership roles.