Techniques aren’t everything: Why conscientious well-trained surgeons make mistakes?
Techniques aren't everything: Why conscientious well-trained surgeons make mistakes?
R. Bethune 0 1
N. Francis 0 1
0 Department of Surgery, Yeovil District Hospital , Yeovil, Somerset BA21 4AT , UK
1 & N. Francis
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The former National Patient Safety Agency in the UK
estimated that there are about three million admissions a
year to NHS hospitals in England, of these about 300,000
have some sort of harm occurring to them, and a further
30,000 will die as a result of those errors. Studies in the
USA and Australia broadly support this figure of about
10 % of all admitted patients coming to harm due to
medical error [1]. This is a higher number than the
combined annual mortality from breast, prostate and colorectal
cancer, so this is a highly significant problem. Half of all
these adverse events are related to surgical patients and
contribute to 13 % of all hospital deaths. Some 40 % of
these events occur in the operating room [2]. Multiple
estimates of adverse events in surgical patients have been
undertaken and fairly consistently come up with a figure of
20 % [3]. That means that 1 in 5 patients experiences an
error in their care that results in harm of some kind and in
4 % the harm is so severe that they die. The conundrum is
this: if surgeons are trained to a very high standard (which
they are) so that they are equipped with the skills and
knowledge to undertake the most difficult surgical
procedures (or any aspect of medicine for that matter), why do so
many mistakes keep happening? The answer comes from
further analysis of these errors. Retrospective reviews
looking at the underlying cause of these errors showed that
only 6 % were related to a lack of knowledge and technical
skill [3]. The surgical community can pat itself on the back
and say that through the multiple training programmes and
efforts from journals such as this one, surgeons of the
future are equipped with the technical skills they need. So
what about the other 94 % of adverse events? The
overwhelming majority (73 %) are related to human factors
(also known as non-technical skills) that the rest of this
article will describe, and the remaining 20 % are related to
organisational systems that made error extremely likely
(i.e. time pressure, locum staff, having patients on
nonspecialist wards, saline and lignocaine in very similar
bottles).
In the simplest terms, human factors are:
communication, team working, leadership, decision-making,
situational awareness, stress and fatigue. The critical point is
they are core to all human behaviour; misreading the road
sign and turning the wrong way down the highway is as
human an error as removing the wrong kidney, only the
severity of the outcome is different. Communication is the
core skill of any health care professional, and this has long
been recognised by surgeons. When operating room
performance is assessed, at least 30 % of communication
episodes result in failure visibly effecting system
processes, including inefficiency, team tension, resource
waste, delay and procedural errors [4].
Nothing in health care is done by individuals alone;
work is done in teams, and surgeons are part of a larger
team that involves staff from theatre, intensive care,
surgical wards, outpatients and other health care professionals
who are involved in the care of the whole patient’s journey.
It therefore follows that how these teams function is critical
to the quality and safety of the care provided. The core
aspect of the most highly functioning teams is interpersonal
relationships. Without a harmonious group climate, teams
will never work to their optimal abilities. All members of
any team need to know what is going on, and they need to
have the same mental model: that is, they all need
situational awareness. One way to help communication, team
working and situational awareness is by conducting both
briefings and debriefings [5].
As the medical community gradually realises the impact
of human factors on harm and poor care, attempts have
begun to address some of these. In a study published in
2009, Atul Gawande and colleagues trialled what has now
become the WHO safer surgery checklist [6]. This
checklist is now universally accepted and practised all over the
world with multiple studies linking its use to a reduction in
surgical complications and mortality [7]. However, the
checklist by itself is not enough, as suggested by a study
that has shown that introduction of the checklist did not
improve surgical outcomes [8]. If people purely pay lip
service to the checklist and do not change their teamwork
and communication behaviours, then the benefits realised
in studies will not occur. Just reading out the items on the
checklist will not reduce the unintentional harm that we do
to our patients in any significant amount. We need to shift
the culture so that surgeons in training and at every other
level consider human factors as important as technical
skills. Current fellowship schemes for senior trainees are
foc (...truncated)