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Surgery Data Belie Slip of Knife


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Surgery Data Belie Slip of Knife

By Tom A. Augello, CRICO

Related to: Communication, Disclosure + Apology, Surgery

Using malpractice claim data, researchers find most surgical mistakes involved system factors.


  • Atul Gawande, MD, MPH; Harvard School of Public Health; Boston, MA
  • Selwyn Rogers, MD, MPH; Brigham and Women’s Hospital; Boston, MA


For professionals looking for ways to reduce medical errors, the low hanging fruit keeps getting higher and higher. If the rule is that everyone makes mistakes, a corollary for patient safety has been that patients can be protected by designing systems that trap mistakes before they harm anyone.

But is surgery different? Are intraoperative errors just the unpreventable result of a flawed individual? New research suggests that the answer is no.

A study in the August issue of the journal Surgery looked at 444 closed malpractice claims from four malpractice carriers around the United States. Dr. Selwyn Rogers is the lead author, and a general surgeon at Brigham and Women’s Hospital in Boston. Dr. Rogers says that research into the causes of error in surgery is still in its infancy. He points out that looking at malpractice data can give researchers more information behind potential errors.

“Closed claim files contain a number of documents that can be used to better understand the nature of medical errors. They include depositions, litigation documents, interrogatories, internal investigations, root cause analyses, and expert opinions from both sides.  By combining all that information, you can often get a more complete picture of an individual malpractice case compared to looking just solely at the medical record.”

Of the 444 claims in the study by Rogers and colleagues, more than 58 percent involved an injury due to an error. These errors often involved multiple phases of care, before, during and after surgery, with three-quarters occurring in the operating room.

“Probably the most striking finding is that even in what we sometimes consider an individual failing with respect to technical errors, that they were often systems factors such as multiple personnel, inexperience or patient-related factors such as abnormal or difficult anatomy that led or contributed to the technical failure."

Dr. Atul Gawande, a co-author on the study with Dr. Rogers, is also a surgeon at Brigham and Women’s Hospital. Dr. Gawande is an assistant professor at the Harvard School of Public Health and Harvard Medical School.

“Sometimes the slip of the hand is just the slip of the hand. You know, you have a very experienced surgeon. They are rested, there is no distractions, and still they cut the nerve. That happens and we saw that in these cases as well, but that is not at all common. Those are the rare instances.  Much more common are seeing factors weighing in that underlie it, that include mostly factors that relate to the preparation for the operating room, also the risks that the patient brings because certain kinds of patients add great complexity to the operation.”

According to Dr. Gawande, the model for understanding how to protect patients from mistakes in health care has been non-surgical, for example: medication error. Looking for solutions in the systems that turn a prescription into a drug in the hands of a patient seems quite different from surgery. An operation is highly complex and technical. Dr. Gawande:

“Surgeons have always had the view that for the most part, error in the operating room happens at the hands of the surgeon, and that if it occurs, it is an individual error that is just traceable to the idiosyncrasies of that person, then it’s not easy to reduce or prevent. What this study showed is that that view is not right.  More than 80 percent of the errors turned out to involve a systems problem, that is, underlying contributing factors that led to errors in judgment or errors in technique.”

When the researchers traced what the patterns were, they began to identify system predictors of the error. The most common factor was inexperience, followed by communication breakdowns. Dr. Rogers says the direction of these findings was a bit of a surprise.

“I was surprised at the nature of the system being so important, that there were so many contributing factors in each of the malpractice cases.  I think there was a sense that we would find that individual failing was the only cause, and in the vast majority of cases there was also one or more system factors.  It would suggest that in order to make surgical care safer, it would need more than one solution.”

Even a factor as seemingly simple as ‘inexperience’ suggests more than one potential system solution. Some ideas to reduce technical error focus on more extensive use of simulators. Preparation models may be part of the solution, or new ways to use electronic patient records for better access to necessary information before, during, and after surgery.

Other ideas focus on group decision making in especially tough cases and expanded use of intraoperative consultation. Dr. Rogers says that, since communication was a major theme, error reduction efforts connected to communication should bear fruit.

“Communication seemed to be a characteristic of many of the cases, contributing to error in about a quarter of the cases. The types of breakdowns included inadequate hand-offs when there were personnel changes or failure to identify a clear line of responsibility, oftentimes communication between physicians and nurses or sometimes inability of the surgeons to reach each other and that would lead to a type of communication breakdown that led to an unfortunate injury.”

In the Harvard system, surgical chiefs at several hospitals have teamed up to review this data and find ways to cut errors. Dr. Gawande is active in the group, which was convened through CRICO/RMF. He says that the initial interventions will focus on communication.

“It turns out, of the communications breakdowns—we are still actually doing an in-depth analysis that we are going to be publishing coming out of this data—our  findings indicate that there are classic kinds of communications breakdowns involving a lack of communication to an attending surgeon when something critical is happening in the hospital, say a patient has begun bleeding and needed a transfusion or has been transferred to the ICU or sometimes even a patient has been admitted to the hospital, but it may be many hours before the attending surgeon is notified. It really has led to a desire to develop triggers, meaning a trigger that would say that the attending surgeon must be contacted when certain kinds of key critical events occur.”

Another aspect of communication being considered for intervention involves hand-offs from one surgeon to another. This would recognize a weak point in the care of patients on surgical units seen in the malpractice data: sign-offs for coverage during nights and weekends.

September 1, 2006
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