SURGERY

A Formula for Errors

Mistakes Happen When Experienced Surgeons Doing Routine Procedures Meet Patient Complexity

Surgery causes the lion’s share of medical complications in hospitals, a fact that has prompted researchers to look for ways to improve safety and reduce errors in surgical procedures. A primary strategy is to shuttle patients to high-volume hospitals and refer them to the most experienced surgeons, particularly for complex, high-risk surgeries. But while experience does pay off for certain operations, Atul Gawande, HMS associate professor of surgery at Brigham and Women’s Hospital, believes that it is not the answer to solving surgical errors. “Despite 10 years of telling people to go to high-volume hospitals, there has been no shift in where they get their care,” he said.

Graham Ramsay

To improve safety, surgeons need to look at treating high-risk patients in routine operations, according to Atul Gawande (right) and Scott Regenbogen.

To find more feasible remedies that will have a broad impact on injury and death, Gawande and his colleagues have been looking more closely at the causes of errors and possible solutions. Their latest study calls into question the idea that experience is the answer. In a paper appearing in the November Annals of Surgery, the team found that surgical errors occur most often with experienced surgeons performing routine operations. They argue that focusing safety efforts on the most difficult procedures and the greenest surgeons will not have a broad impact on public health. “If we want to understand how to save more lives in the health care system, we have to understand why experienced surgeons doing routine operations have complications,” Gawande said.

Routine Derailed
The study arose from a large project funded by the Harvard Risk Management Foundation and the federal Agency for Healthcare Research and Quality that collected a database of surgical malpractice claims to glean information about mistakes in the OR. Though claims information misses the vast majority of errors that occur in operating rooms, it gives researchers a detailed picture of the problems behind the most serious cases. In this investigation, the researchers focused on technical errors, which they define as both manual mistakes (such as making an incorrect incision) as well as errors of knowledge or judgment that lead a surgeon to perform an incorrect or inadequate procedure.

Technical errors were involved in a little more than half of the 444 claims in the sample. The researchers discovered that 73 percent of these involved experienced surgeons. When the team looked at the causes, they found that 84 percent of the errors occurred during routine operations as opposed to more difficult ones that carry a higher risk. Yet more than 60 percent occurred in circumstances of increased patient or procedure-related complexity—such as having an emergency surgery, a particularly difficult anatomy, or scarring from a previous surgery.
“In order to do the perfect operation, so many things need to go right,” explained Scott Regenbogen, the paper’s first author, who is a surgical resident at Massachusetts General Hospital and a postdoctoral fellow at HSPH. “Once the patient is more complicated, doing all those things right becomes more complicated.”

Another recent study from Gawande’s team also put experienced surgeons in the spotlight. That work, published in the April Journal of the American College of Surgery, tackled another major type of surgical error: problems with communication. Regenbogen said that conventional wisdom often puts the blame on residents that hand off patients to one another after shifts. But instead, he said, “we found that attending surgeons tend to be at the center” of communication breakdowns. Sometimes the breakdown resulted from a resident failing to pass along vital information to an attending surgeon, or from attendings covering for one another, and many errors were caused by some ambiguity about responsibility.

Regenbogen said that the main lesson of the study was that attendings, who are the primary decision-makers, also tend to be at the center of communication. Knowing this, he said, “a few relatively straightforward interventions could make a big difference.” For example, a hospital could implement mandatory triggers for immediately contacting an attending surgeon and create more structured ways to transfer information.

Navigating a Storm
Richard Karl, chair of the Department of Surgery at the University of South Florida College of Medicine, pointed out in an accompanying editorial that the results of the current study are “at once surprising and not a surprise at all.” The oft-cited statistic that most car accidents occur close to home is a no-brainer considering the proportion of driving that occurs in one’s neighborhood as opposed to anywhere else. But Karl explained that the message of this study would still come as a surprise to the surgery community. “The supposition among many academic surgeons is that ‘it’s not me making the mistakes, it’s an inexperienced person or a person doing surgical operations in a low-volume center,’” he said. Looking at the problem from a public health perspective “is new to our discipline.” He contrasts surgery to the aviation industry, where checklists, oversight, and structured communication are the norm. On airlines, he pointed out, it’s common to have a discussion of plans for flying in bad weather, but there is no such plan for operating on a complex patient.

Gawande hopes the research opens up a discussion about ways to do just that and wonders if there should be a discipline focused on the care of high-risk patients in general medicine, similar to the specialty in obstetrics of caring for high-risk pregnancies. “We need to devise strategies for the complex patient and not just strategies for the super-difficult surgeries,” he said. But he and Regenbogen concede that identifying those sorts of strategies will be trickier. And the message for patients is also less satisfying; after all, seeking out the most seasoned surgeon at the busiest hospital is something that patients can control far more easily than their own complexity.

—Courtney Humphries

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