Errors in surgery. Strategies to improve surgical safety

Surgery is an extreme experience for both patient and surgeon. The patient has to be rescued from something so serious that it may justify the surgeon to violate his/her integrity in order to resolve the problem. Nevertheless, both physician and patient recognize that the procedure has some risks. Medical errors are the 8th cause of death in the U.S., and malpractice can be documented in >50% of the legal prosecutions in Mexico. Of special interest is the specialty of general surgery where legal responsibility can be confirmed in >80% of the cases. Interest in mortality attributed to medical errors has existed since the 19th century; clearly identifying the lack of knowledge, abilities, and poor surgical and diagnostic judgment as the cause of errors. Currently, poor organization, lack of team work, and physician/ patient-related factors are recognized as the cause of medical errors. Human error is unavoidable and health care systems and surgeons should adopt the culture of error analysis openly, inquisitively and permanently. Errors should be regarded as an opportunity to learn that health care should to be patient centered and not surgeon centered. In this review, we analyze the causes of complications and errors that can develop during routine surgery. Additionally, we propose measures that will allow improvements in the safety of surgical patients.     

Can Medical Simulation and Team Training Reduce Errors in Labor and Delivery?

Patient safety is one of the most pressing challenges in health care today, and there is no question that medical errors occur and that patients are worried about them. Currently, there is a belief that the availability of medical simulations and the knowledge gained from the science of team training may improve patient outcomes, and there is a paradigm shift occurring in many universities and training programs. This article discusses two strategies that, when combined, may reduce medical error in the labor and delivery suite: team training and medical simulation.     

Automation, decision support, and expert systems in nephrology

Increasing data suggest that errors in medicine occur frequently and result in substantial harm to the patient. The Institute of Medicine report described the magnitude of the problem, and public interest in this issue, which was already large, has grown. The traditional approach in medicine has been to identify the persons making the errors and recommend corrective strategies. However, it has become increasingly clear that it is more productive to focus on the systems and processes through which care is provided. If these systems are set up in ways that would both make errors less likely and identify those that do occur and, at the same time, improve efficiency, then safety and productivity would be substantially improved. Clinical decision support systems (CDSSs) are active knowledge systems that use 2 or more items of patient data to generate case specific recommendations. CDSSs are typically designed to integrate a medical knowledge base, patient data, and an inference engine to generate case specific advice. This article describes how automation, templating, and CDSS improve efficiency, patient care, and safety by reducing the frequency and consequences of medical errors in nephrology. We discuss practical applications of these in 3 settings: a computerized anemia-management program (CAMP, Henry Ford Health System, Detroit, MI), vascular access surveillance systems, and monthly capitation notes in the hemodialysis unit.     

Assessment of Patient Knowledge of the Role of Advanced Practice Providers in Transplantation Surgical Care: A Single-Center Prospective Study

BackgroundAdvanced practice providers (APPs) are integral to the contemporary transplant surgeon–APP practice model. Patient understanding of APPs’ role is vital for optimal patient care and experience. Data on patient knowledge of APPs’ roles remain scarce. We sought to assess patient awareness of APPs in their transplantation surgical team.MethodsWe conducted a prospective study on 100 consecutive transplant candidates and recipients ≥18 years, hospitalized in the transplant surgeon–APP Transplantation Intensive Care Unit (primary service) from September 16, 2019 through June 10, 2021. All patients received a 5-question survey (Table 1). Group 1 (first 50 patients) did not receive any printed introductory materials (Figs 1 and 2) before completing the questionnaire, whereas group 2 (last 50 patients) completed the survey after receiving the materials.ResultsAlthough > 90% of patients were knowledgeable about physician assistants (PAs) and nurse practitioners (NPs), the term “advanced practice providers” was unfamiliar to patients in both groups (Table 1). The level of patient recognition and comfort with APPs in the transplant surgeon–APP care team were comparable for both groups.ConclusionsOur study showed that transplant candidates and recipients were knowledgeable and highly comfortable that PAs and NPs are members of their transplantation surgical team. However, the term advanced practice providers was unfamiliar to the patients. Our study suggested that patient education on provider terms used in current health care delivery is essential and may enhance the patient experience.     

Errors and adverse outcomes on a surgical service: what is the role of residents?

PURPOSE: The extensive changeover in residents that occurs every July in university-affiliated hospitals has been postulated to result in impaired delivery of patient care as new house staff are less experienced and unfamiliar with hospital-specific systems (the "July phenomenon"). To assess the impact of this process on patient safety, we examined the incidence and sources of medical error and adverse outcomes on a pediatric general surgery service during the final month of an academic year and the first month of the subsequent academic year. MATERIALS AND METHODS: All admissions to two pediatric surgeons during June and July 2002 were prospectively followed. The attending surgeon, a surgical fellow, and a medical student reviewed in-patient care daily. Errors committed by doctors, nurses, and allied health workers were identified through daily patient encounters, nursing rounds, medical rounds, and chart audit. Adverse outcomes were evaluated based on type and contributing factors, including involvement of residents. To correct for variations in patient volume, the incidence of errors and adverse outcomes were expressed as a percentage of total patient days. RESULTS: The error rate was 46/643 patient days (7.1%) in June, and 58/776 patient days (7.5%) in July (P = 0.9). Resident error accounted for 52.2% of errors in June and 39.7% of errors in July (P = 0.28). There was no significant difference in the adverse outcome rates (5% versus 6.7%, P = 0.21) or incidence of error-related adverse outcomes (10.8% versus 22.4%, P = 0.2) between June and July. Most errors were made by the on-call resident. CONCLUSION: Resident changeover at the completion of an academic year did not result in an increased number of medical errors or adverse outcomes, indicating that effective systems are in place to prevent the "July phenomenon."     

Maintaining safety management in the field of surgery

Due to an increase in the number of medical accidents and medical conflicts, the administration of medical safety has recently introduced the following measures to cope with this situation; the process and the structure (reason) of error is analyzed based upon evidential facts, the origin of the errors is analyzed mainly in terms of teamwork and specialized medicine and structures rather than in terms of the ability of the individual, and the strategy against medical errors has been converted from aspects of management to prevention. The comprehensive strategy pursued now covers the field of social medical systems in addition to medical institutions. However, the judicial decisions in 90% of medical conflicts ruled that these were caused by the lack of knowledge and skills of the medical doctor, and a survey performed by the Japan Medical Association based on medical insurance research has reported incidences of repeated medical errors by the same physician. This has led to some criticism from the victim's viewpoint that insufficient administration of medical quality result in increased numbers of accidents which are due to repeated medical errors, under "legal" medical practice by "incompetent" doctors who should have been systematically reeducated or dismissed. In recent years, several societies and research groups of the Ministry of Health, Labour and Welfare have constructed medical guidelines based on evidence-based medicine techniques. The introduction of the clinical pathway offers the medical team access to information, directed to the appropriate roles, which may be helpful in performing constant safety checks. This medical check method that involves the patient's input will also contribute to the prevention of medical errors and promotion of safety.     

Limiting harm in the ICU

This year, the US Institute of Medicine has estimated that medical errors kill up to 98,000 Americans each year,1 a problem surpassing automobile fatalities. For patients on the medical ward, drug therapy is the primary intervention they are receiving yet medication errors occur in as many as 4% of inpatients.2 Although greater monitoring intensity and much lower nurse-patient ratios in the ICU may reduce the incidence of medication errors, the shear number if interventions dramatically increases the risk of error.3 Furthermore, the study by the Institute of Medicine only addressed a small part of the problem. The taxonomy of errors includes both "accidents" (skill-based errors) and intentional "mistakes" (knowledge-based and rule-based errors).2 Thus, the Institute of Medicine would not consider the proscribing of human growth hormone for cachexia an error unless the proscribed dose was not administered or it was given to the wrong patient. In the ICU, the risks associated with both kinds of errors are considerable. In this review we will focus on the second kind of errors and examine harms associated with the care of patients with sepsis.     

Medication errors in anaesthesia and critical care

There is an increasing recognition that medication errors are causing a substantial global public health problem, as many result in harm to patients and increased costs to health providers. However, study of medication error is hampered by difficulty with definitions, research methods and study populations. Few doctors are as involved in the process of prescribing, selecting, preparing and giving drugs as anaesthetists, whether their practice is based in the operating theatre, critical care or pain management. Anaesthesia is now safe and routine, yet anaesthetists are not immune from making medication errors and the consequences of their mistakes may be more serious than those of doctors in other specialties. Steps are being taken to determine the extent of the problem of medication error in anaesthesia. New technology, theories of human error and lessons learnt from the nuclear, petrochemical and aviation industries are being used to tackle the problem.     

Knowledge and attitude regarding organ donation among medical students and physicians

BACKGROUND: There is a discrepancy between demand and supply of donor organs for kidney transplantation. Health care providers can influence the willingness to donate or hold an organ donor card. It is unclear how educated current and future health care professionals are about organ donation and what constitutes their attitude toward this topic. METHODS: The authors conducted a cross-sectional survey among 1136 medical students and physicians to evaluate the knowledge about and attitude toward organ donation and transplantation at a large academic medical center in Germany. The authors used a 28-item questionnaire that included items on knowledge, attitude, and demographics. RESULTS: Only 8% of the respondents felt sufficiently prepared for approaching relatives of potential organ donors. Knowledge about and attitude toward organ donation were highly associated with increasing level of medical education. In multivariate analyses, knowledge (odds ratio [OR], 1.17; 95% confidence interval [CI], 1.08-1.25), attitude (OR, 1.03; 95% CI, 1.02-1.04), and level of education (OR for preclinical students, 0.39; 95% CI, 0.20-0.76 compared with physicians) were significantly associated with the likelihood of holding an organ donor card, whereas age, gender, and personal experience with renal replacement therapy were not. CONCLUSIONS: Higher medical education is associated with greater knowledge about and a more positive attitude toward organ donation. Health care professionals with a higher education level are more likely to hold an organ donor card and also feel more comfortable in approaching relatives of potential organ donors. Educating health care professionals about the organ donation process appears to be an important factor in maximizing the benefits from the limited organ donor pool.     

Uncertainty in knowing the operating rooms in which cases were performed has little effect on operating room allocations or efficiency

At many US surgical facilities, applying the previously published method that maximizes the efficiency of use of operating room (OR) time is an effective way to optimize the allocation of OR time. Results are resistant to small errors in recorded OR times. However, at some facilities, the OR information systems data have as much as a 10% error in the correct OR where each case took place. This decreases the total OR time attributed to each service, which is the basis for the allocation method. Such errors could result in incorrect OR allocations and increased OR staffing costs. Expensive and time-consuming data-cleaning steps may be required to resolve the actual OR allocation for each case. We used 1 yr of data from a large, tertiary academic hospital to investigate, through simulation, how increasing levels of error in the correct OR affect OR efficiency and allocations. To apply noise to the data, the actual ORs were changed randomly to unique, "unknown" rooms. At a 30% error level, OR allocations decreased by 4.8%, and costs increased by 1.4% relative to knowing the actual location of every case. Only 1 of 11 surgical services had an allocation decrease at room error rates of less than 25%. We conclude that, in most circumstances, data-cleaning steps to resolve uncertainty in OR locations are not necessary to make accurate OR allocations. IMPLICATIONS: Up to a 30% uncertainty in knowing the actual operating room (OR) in which cases were performed had a minor effect on OR allocations to maximize OR efficiency and on the resulting staffing costs. Thus, facilities with this common error in their OR information systems data will generally be able to use their existing data for accurate OR allocations.     

Human error in medicine: change in cardiac operating rooms through the FOCUS initiative

Human error in medicine is a significant cause of patient mortality. While there has been increased attention to safety in medicine since the Institute of Medicine publication To Err is Human, the profession at large has not progressed to the same degree as other highly complex industries such as aviation and nuclear power. The Flawless Operative Cardiovascular Unified Systems initiative (FOCUS) is a multi-year study/intervention to learn about and to improve human error in cardiac surgery. FOCUS has developed into an ongoing re-focusing through prospective interventional research schemes designed to effect positive change for improved patient care in cardiac surgery. The program was developed in conjunction with the Johns Hopkins University Quality and Safety Research Group using an approach termed locating errors through network surveillance (LENS). The LENS process was undertaken at Johns Hopkins University and another five centers where three major areas were examined observationally: interactions (communication) between operating room cardiac team members, clinical performance of known quality and safety dependent processes, and ergonomics/safety or human-machine interfaces. While collected data is currently being analyzed, preliminary results reveal over 800 human errors noted in the 40 cases observed. The errors observed are being categorized and taxonomy of errors is being created. Categories used in the FOCUS analysis include: teamwork and communication, compliance with existing protocols, knowledge or supervision, vigilance or situational awareness, equipment failure/design, poor operating room design/ergonomics, handoffs and transport problems, lack of professionalism, and ambiguity of responsibility. FOCUS is an initiative to change practice driven by science. Interventions based upon the observations already underway include efforts to decrease infection, adoption of the aviation concept of the "sterile cockpit", briefing and debriefing, reduction of drug error, and peer-to-peer assessment. The first FOCUS data is sobering and shows tremendous possibility for improvement.     

Management of a fire in the operating room

Operating room (OR) fires remain a significant source of liability for anesthesia providers and injury for patients, despite existing practice guidelines and other improvements in operating room safety. Factors contributing to OR fires are well understood and these occurrences are generally preventable. OR personnel must be familiar with the fire triad which consists of a fuel supply, an oxidizing agent, and an ignition source. Existing evidence shows that OR-related fires can result in significant patient complications and malpractice claims. Steps to reduce fires include taking appropriate safety measures before a patient is brought to the OR, taking proper preventive measures during surgery, and effectively managing fire and patient complications when they occur. Decreasing the incidence of fires should be a team effort involving the entire OR personnel, including surgeons, anesthesia providers, nurses, scrub technologists, and administrators. Communication and coordination among members of the OR team is essential to creating a culture of safety.     

Defining medical error.

Medical errors represent a serious public health problem and pose a threat to patient safety. As health care institutions establish “error” as a clinical and research priority, the answer to perhaps the most fundamental question remains elusive: What is a medical error? To reduce medical error, accurate measurements of its incidence, based on clear and consistent definitions, are essential prerequisites for effective action. Despite a growing body of literature and research on error in medicine, few studies have defined or measured “medical error” directly. Instead, researchers have adopted surrogate measures of error that largely depend on adverse patient outcomes or injury (i.e., are outcome-dependent). A lack of standardized nomenclature and the use of multiple and overlapping definitions of medical error have hindered data synthesis, analysis, collaborative work and evaluation of the impact of changes in health care delivery. The primary objective of this review is to highlight the need for a clear, comprehensive and universally accepted definition of medical error that explicitly includes the key domains of error causation and captures the faulty processes that cause errors, irrespective of outcome.     

Health informatics and the importance of coding

Health informatics can be defined as ‘The knowledge, skills and tools which enable information to be collected, managed, used and shared, to support the delivery of healthcare and to promote health.’ The use of computers in informatics requires standardized codes to identify synonymous medical terms. The International Statistical Classification of Diseases and Related Health Problems, 10th revision, (ICD-10) is used internationally to code morbidity and mortality; the Office of Population Censuses and Surveys Classification of Surgical Operations and Procedures, 4th revision, (OPCS-4) is used in the UK to code operations and procedures; Read codes and Clinical Terms Version 3 (CTV3) are used in primary care systems. Systemized Nomenclature of Medicine Clinical Terminology (SNOMED CT) incorporates all these coding systems. ICD-10 and OPCS-4 are fundamental to Payment by Results, the method by which healthcare providers in the NHS in England are paid.     

Race, gender, and socioeconomic disparities in CKD in the United States

Chronic kidney disease (CKD) is a national public health problem beset by inequities in incidence, prevalence, and complications across gender, race/ethnicity, and socioeconomic status. As health care providers, we can directly address some factors crucial for closing the disparities gap. Other factors are seemingly beyond our reach, entrenched within the fabric of our society, such as social injustice and human indifference. Paradoxically, the existence of health inequities provides unique, unrecognized opportunities for understanding biologic, environmental, sociocultural, and health care system factors that can lead to improved clinical outcomes. Several recent reports documented that structured medical care systems can reduce many CKD-related disparities and improve patient outcomes. Can the moral imperative to eliminate CKD inequities inspire the nephrology community not only to advocate for but also to demand high-quality, structured health care delivery systems for all Americans in the context of social reform that improves the ecology, health, and well-being of our communities? If so, then perhaps we can eliminate the unacceptable premature morbidity and mortality associated with CKD and the tragedy of health inequities. By so doing, we could become global leaders not only in medical technology, as we currently are, but also in health promotion and disease prevention, truly leaving no patient behind.     

Daedalus revisited: a call for redesign of the bougie esophageal dilator

We report a case of a patient undergoing gastric bypass in which an improperly introduced bougie dilator resulted in esophageal perforation and we examine the matter using a human-factors approach. The Institute of Medicine's widely distributed 1999 report estimated that up to 98,000 Americans die each year as a result of preventable errors with the operating room being a particularly error-prone environment. The report suggests that the majority of errors are not the result of poor provider performance but instead are the result of inherent systems-based problems. Perforation can be associated with significant negative outcome; modifying factors include experience, appreciating anatomical details, and cognizance of mechanisms of perforation. Human-factors research reveals that 1) humans are prone to err and 2) the majority of errors are not the result of personal inadequacy but instead are the product of defects in the design of health care environmental systems in which that work occurs. Here during a highly complex surgical procedure a simple preventable human error occurred, one often associated with significant negative outcome. We suggest a simple solution in line with a human-factors approach that might prevent future occurrences.     

High-performance teams for current and future physician leaders: an introduction

The scope of patient management increasingly crosses the defined lines of multiple medical specialties and services to meet patient needs. Concurrently, many hospitals and health-care systems have adapted new multidisciplinary team structures that provide patient-centric care as opposed to the more traditional discipline-centered delivery of care. As health care continues to evolve, the use of teams becomes even more critical in allowing interdependence between multiple disciplines to provide excellent care delivery and ongoing patient management. The use of teams permeates the health-care industry (and has done so for many years), but confusion about the structure, role, and use of teams contributes to limited effectiveness. The health-care industry's underuse of the fundamentals of corporate teamwork has, in part, created ineffective team leadership at the physician level. As the first in a series of documents on teamwork, this article is intended to introduce the reader to the rudiments of team theory and to present an introduction to a model of teamwork. The role of current and future physician leaders in ensuring team effectiveness is emphasized in this discussion. By educating health-care professionals on the foundations of high-performance teamwork, we hope to accomplish two main goals. The first goal is to help create a common and systematic taxonomy that physician leaders and institutional management can agree on and refer to concerning the development of high-performance health-care teams. The second goal is to stimulate the development of future physician leaders who use proven teamwork principles as a powerful modality to achieve efficient and optimal patient care. Most importantly, we wish to emphasize that health care, both philosophically and practically, is delivered best through high-performance teams. For such teams to perform properly, the organizational environment must support the team concept tangibly. In concert, we believe the best manner in which to cultivate knowledge and performance of the health-care organizational mission and goals is by using such teams.     

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.     

A new safety event reporting system improves physician reporting in the surgical intensive care unit

BACKGROUND: Medical errors are common, and physicians have notably been poor medical error reporters. In the SICU, reporting was generally poor and reporting by physicians was virtually nonexistent. This study was designed to observe changes in error reporting in an SICU when a new card-based system (SAFE) was introduced. STUDY DESIGN: Before implementation of the SAFE reporting system, education was given to all SICU healthcare providers. The SAFE system was introduced into the SICU for a 9-month period from March 2003 through November 2003, to replace an underused online system. Data were collected from the SAFE card reports and the online reporting systems during introduction, removal, and reimplementation of these cards. Reporting rates were calculated as number of reported events per 1,000 patient days. RESULTS: Reporting rates increased from 19 to 51 reports per 1,000 patient days after the SAFE cards were introduced into the ICU (p相似文献