The Doctor’s Advocate | Third Quarter 2015
Minimizing Surgical Errors
This quarter, Director’s Forum features a guest editorial by Jonathan Jones, MD, who offers practical suggestions for avoiding surgical errors. Dr. Jones practiced reconstructive plastic surgery and hand surgery in San Diego for more than 31 years. He recently retired as a longtime member of The Doctors Company.
I would like to encourage you to read “Teamwork in the OR,” our companion article that discusses a focused team approach to resolving problems and concerns.
—David B. Troxel, MD
It is every surgeon’s goal to obtain a good outcome and to improve the well-being of the patient. Simply stated, the surgeon’s goal is to treat the patient as he or she would like to be treated. As a colleague stated, we are held to a high standard and are expected to “hit a home run every time we are at bat.” A few practical suggestions are offered with the hope that many preventable “strikeouts” can be avoided.
Before embarking on an operative procedure, the surgeon should ask “Am I the best-qualified person to be doing this procedure?” An expert general surgeon with whom I work is fully capable of performing the complex Whipple procedure. He has elected instead to refer patients needing this procedure to surgeons who have had more experience. Although I have enjoyed the challenge of toe-to-hand transfers, I have elected to refer these cases to specialty clinics where the procedure is performed more regularly. Pride must take a back seat to common sense.
Planning should be done prior to entering the operating room. Each step of the procedure should be thought out in detail. The surgeon should ask “What structures must I avoid injuring?” Anatomy atlases should be reviewed regularly. A backup plan should be considered that allows for the possibility of anatomic variants. The operative consent form should include potential backup procedures that might become necessary. The goal should be to perform the simplest procedure that would meet the patient’s needs. Why do a complex flap transplantation procedure when a skin graft will suffice?
Careful evaluation of the patient prior to surgery can prevent surgical disasters. Biopsies should be performed liberally. Benign-appearing skin lesions could be cancer. The patient should be told that the diagnosis cannot be made until a biopsy is sent to the pathologist. Medical students are often taught “When you hear hoofbeats, think horses and not zebras.” It is unlikely that a horse will bite you, but a zebra certainly will. It is what you do not expect that could cause great trouble. The “in my experience” teaching of a respected professor reflects one person’s narrow sampling of the patient population and should be supplemented by a review of the literature. A literature search by a medical librarian may be very thorough, but a quick online search to access respected medical sources can yield important and helpful information.
Advancements in imaging techniques have aided greatly in preoperative planning. Magnetic resonance imaging of a soft tissue mass might reveal a liposarcoma instead of what appears to be a lipoma. A fine needle aspirate (FNA) by an interventional radiologist might greatly alter the surgical procedure (an exception is a breast mass, which should be removed even if the FNA is negative). Preoperative consultation with radiology colleagues can be very beneficial.
Forwarding a list of specialized equipment and supplies to the operating room several days prior to the procedure will help prepare the operative team. The anesthetic should not be administered until the availability of necessary surgical instruments, implants, and special medications has been assured.
We in medicine have the privilege of working with nurses and technicians who desire to help others. They should be recognized and appreciated for their work. An operating room environment should be established in which the assistants are encouraged to ask questions and make suggestions. The object is not to seek their praise but to accept their observations, if valid. A nurse with whom I was working pointed out that a kink was present in a soft tissue pedicle and that the perfusion of the tissues appeared reduced. I unkinked the pedicle, restored circulation to the tissues, and ultimately obtained a good outcome.
Positioning of the patient should be supervised by the surgeon and the anesthesiologist. Bony prominences should be padded carefully. The “bean bag” trunk support becomes very firm when suction is applied. This may result in excessive pressure on the down side arm and result in a radial nerve palsy. The surgeon should also verify that pulsatile stockings for prevention of deep vein thrombosis are operational and that warm air heating blankets are appropriately placed.
The electrocautery pencils should be holstered when not in use. This is especially important when two electrocautery units are used concurrently. Leaning on an electrocautery pencil caught beneath drapes could result in an accidental burn injury.
Of the few errors I have observed in surgery, most have been the result of the surgeon being in a rush. Incorrect incisions could be placed, nerves transected, important blood vessels ligated, and inadequate hemostasis could result from the surgeon rushing. By securing hemostasis as the operation progresses, there will be fewer instances of “take-back” operations for evacuation of hematomas.
Excessive fatigue can also affect the surgical outcome adversely. If the surgeon has been up the night before a scheduled operative procedure, it is preferable to cancel the case and reschedule it for another date. A malpractice attorney and physician stated that many court cases have resulted from poor judgment of excessively fatigued physicians. Be rested so as to not only do the operation well but to also manage postoperative care expertly.
It is now standard practice that correct sponge, needle, and instrument counts are obtained prior to the transfer of patients to the recovery room. Unfortunately, retention of sponges and instruments has been reported despite correct counts. These problems are more common in long operations where there is a change in shift and when the patient is obese. Therefore, the report of a correct sponge, needle, and instrument count cannot be entirely relied upon. Although surgeons do not do the counts, they may be held liable should a retained foreign body result. It is imperative that the surgeon inspect the entire operative field carefully prior to closure. If any concern remains, a radiograph should be obtained.
Careful preoperative planning, teamwork, attention to detail, and patience will minimize surgical errors and help to secure a “home run” surgical outcome.