Several recent studies claim that avoidable medical errors are responsible for 250,000 to 450,000 patient deaths per year. If this research is correct, then errors in medical care would be the third leading cause of death in our country; only cancer and heart disease cause more. It is no surprise that hospitals, medical societies, and several accrediting bodies are looking for ways to minimize the number of these deaths.
I have been doing surgical operations, either as a resident or attending, going on 40 years. I learned early in my career that the operating room could be a site where adverse events could occur to the patient and to the health care providers involved with the operations. Much like the airline industry has improved its safety record, patient safety in the operating room has also improved. Recognizing that humans make mistakes, specific processes are now part of the operating room routines meant to minimize individual errors and a culture of open communication with all members of the operating room team allow for anyone to voice issues of concern. These steps have gone a long way to improving patient safety.
There will always be technical and judgment errors made in the operating room (OR); even surgeons are human. The area where most progress is being made is with the processes. Before the patient is brought into the OR, he must state his name and an identifying characteristic such as his birthday or his social security number. He must also state what operation is being done and on which part of the body. This minimizes the risk for wrong patient, wrong operation, and wrong surgical site. One of the responsible surgeons must mark the site of the planned operation prior to moving the patient to the OR.
After the patient has been moved to the operating room and before he is put to sleep, one of the operating surgeons does a “briefing.” During the briefing, all members of the OR team must pay attention while the details of the planned procedure are discussed. A checklist is used to go over the patient’s name and social security number, the planned procedure and the body site to be operated on. Also, the perioperative antibiotics, allergies, blood availability, special equipment needs, and a check of possible implants, including the expiration dates, are reviewed.
Since flammable gases and flammable chemicals are often used in the OR—remember, even oxygen can feed a fire—an assessment for possible fires is also done. Chemical preps are allowed to dry before electrocautery is used and the anesthesiologist decreases the amount of inspired oxygen if the cautery or laser is going to be used nearby such as in the airway.
A “time-out” is done before any incision is made. This is the last check before an incision and the elements of the briefing are revisited at this time.
At the conclusion of the procedure, a debriefing is done; again a checklist is used and is recorded in the operative nurses’s notes. Equipment issues, educational opportunities to better perform the procedure in the future, anesthetic issues, and drug interactions are discussed and areas for improvements are documented.
In the past, the surgeon ran the OR and he was not to be second guessed. Now, anyone in the OR has been empowered to “stop the line” if they see something that concerns them. A surgeon who ignores the concerns of his colleagues does so at his own, and the patient’s peril. Most of the surgeons I know are very receptive to being made aware of a possible dangerous situation before it is too late.
The patient is not the only one at risk in the operating room.
I have suffered numerous needle sticks though the years and have even been cut by physicians in training. In most of these cases, it was my fault for not being as attentive as I should have been.
For a brief period of time, I got very sick and it was felt that I had an infectious disease from exposure to a patient’s bodily fluids (blood). I was easily exhausted and could only do one case before I had to lie down for the rest of the day. My liver function tests were elevated. As a university surgeon, several physicians became involved in my care. I was tested for “mono” (Ebstein Barr virus), Hepatitis B and C, and Human Immunodeficiency virus (HIV). All of these tests were negative. Finally, Cytomegalovirus (CMV) titers came back significantly elevated. This virus is actually very common in the blood and many surgeons are exposed. Fortunately, this infection, although temporarily disabling, eventually runs its course and the liver recovers. I was relieved to know that I was not going to die, at least in the short term.
Now there are numerous safety devices that have been added to equipment to minimize the risks of injury both to the patient and operating room personnel. There are safety shields placed over scalpels and the needles used for vascular access. There are special tags placed on laparotomy pads and sponges which can be detected by special scanners if the counts show a discrepancy. There are specific policies that must be followed if the counts show that something is missing at the end of the procedure. These policies mandate a cavity search by the surgeon and specific radiographs of the operative field(s). The patient does not leave the OR until the radiographs are cleared by a radiologist who has been told what to look for.
Although it is unlikely that errors in the operating room will ever be totally eliminated, on-going research to minimize human errors, institutional policies to meet national patient safety goals through the use of incident reporting, implementing evidence-based best practices, using simulation models to learn about equipment and techniques before using them on actual patients, and establishing open communication in the operating room where everyone is free to voice concerns, should go a long way in decreasing the chances for an OR misadventure. As Hippocrates wrote, “First do no harm.” Minimizing OR errors would go a long way to meeting this obligation.
Dr. Weiman’s website is www.medicalmalpracticeandthe law.com