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  Technical errors can occur in surgical practice

  
  
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  The best way to reduce technical errors is prevention

  
  
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  Prevention of errors is important to reduce surgical morbidity and mortality

The Institute of Medicine defines error as “the failure of a planned action to be completed as intended (ie, error of execution) or the use of a wrong plan to achieve an aim (ie, error of planning).” According to a 1999 Institute of Medicine report, errors in health care are the eighth leading cause of death in the United States and account for up to 100,000 deaths annually. In particular, technical errors, which include errors of judgment, lack of knowledge, and manual errors, can lead to surgical adverse events.

In surgery, highly invasive procedures, technical difficulties, and patients’ comorbidities are all factors contributing to the risky condition of surgical practice; in fact, between one-half and two-thirds of hospital adverse events are attributable to surgical care. Gawande et al examined 15,000 patient records and found that 66% of all adverse events are surgical and that 54% of these are preventable.¹ If it is true that every intervention in medical practice carries a certain level of risk, even the simplest surgical procedure has the potential to develop into an adverse event: there are thousands of maneuvers in a routinely performed operation and each of these carries the opportunity of an adverse event.

All these issues have generated a broad interest in the prevention of adverse events in health care. Every single surgeon should know what to expect when performing a procedure, what to do to prevent the occurrence of potential problems and, of course, how to minimize the adverse event to reduce the negative effects.

Regenbogen et al reported that attending surgeons are responsible for 69% of surgical errors, with another 27% involving both attending surgeons and trainees.² Only 4% of errors are attributed to residents and fellows alone. The most common types of operations associated with errors are general or gastrointestinal surgery (31%), spine surgery (15%), gynecologic surgery (12%), and nonspine orthopaedic surgery (9%). Ninety-one percent of the technical errors involve manual error and 35% involve judgment or knowledge error. About 65% of technical errors involve manual error only, while 27% involve both manual and judgment or knowledge components. Few involve solely knowledge or judgment errors (9%). The most common specific errors are incidental visceral injury (34%), the breakdown of operative repair or failure to relieve the disease (16%), hemorrhage (16%), and peripheral nerve injury (14%). Retained surgical equipment accounts for 3% of errors. Errors of judgment or knowledge include delay or error in intraoperative diagnosis or management (16%), incorrect choice of procedure or technique (9%), and wrong operative site (7%). A minority of technical errors involve index operations (16%), inexperienced surgeons (8%), surgeons operating outside their area of expertise (5%), or unexpected events that require skills outside a surgeon’s area of expertise (1%). A majority (84%) represent routine operations, and 73% involve experienced surgeons operating within their area of expertise and training. Therefore, almost three-quarters of technical errors in this study involve fully trained and experienced surgeons operating within their area of expertise and 84% occur in routine operations, for which advanced expertise beyond a standard training program is not required or expected. These errors occur predominantly in situations complicated by comorbidity, a complex anatomy, repeat surgery, or equipment problems.

In order to have a major initial impact, strategies to reduce patient harm from surgical error must address the most prevalent types of failures. Therefore, significant potential may reside in strategies to improve decision making, operative planning, and team performance for common operations, particularly in high-risk circumstances such as emergencies, reoperation, and patients with an unusually difficult anatomy. Peer consultation, collaboration, implementation and the standardization of evidence-based perioperative processes of care, team training, and simulation for difficult circumstances are also important.³ These data suggest that to prevent the largest number of injuries and make the greatest improvements in surgical safety, further research should focus on designing targeted interventions to improve decision making and performance in routine operations for high-risk patients and in high-risk circumstances.

However, what are the most common causes of error-related events? As already mentioned, surgery itself is predisposed to adverse events by definition. Technical errors are the most important part of this field for two reasons: (1) because they have a profound impact on complications, and (2) because they are preventable. Technical errors can be either attributable to direct manual errors such as sectioning the wrong artery or wrong duct or to knowledge and judgment issues such as delaying intervention in a potentially rupturing aortic aneurysm. In both conditions, some important factors are associated with these technical errors, making it, on the one hand, difficult to interpret what went wrong and, on the other hand, complicating the possibility of intervention at different levels. These factors are related to both the patient and the surgeon/hospital setting. It is clear that an unusual anatomy, reoperation, an emergency procedure, and comorbidity are responsible for technically demanding operations as are factors such as surgeon fatigue/inexperience, low hospital/surgeon volume of patients, and operating trainees. Each of these factors suggests that a variety of interventions to prevent the occurrence of adverse effects is possible. Hence, a highly specific and focused study of the anatomy; risk-reduction strategies for high-risk circumstances; the stabilization of comorbidities; mentoring, consultation and training for young surgeons; and high-volume referrals to specialized centers are all crucial.

Leape et al, in an article published in the New England Journal of Medicine, pointed out that the second most common class of error is related to the failure to take preventive measures and that 60% of these involve negligence.⁴ The presence of an error is thus a necessary but not sufficient condition for the determination of negligence.

Despite the general introduction to the problem, it is incorrect to speak about technical errors in surgery without classifying the pitfalls according to the subspecialties of surgical care. Different operations have different risks in terms of safety and result in different outcomes: the most common types of operations associated with technical errors are general or gastrointestinal surgery, spine surgery and gynecologic surgery. The leading role of general and gastrointestinal surgery could be imputed first to the high frequency and high number of these procedures, ranging from inguinal hernia to splenic rupture, and to the presence of a complex anatomy.

It is also important to evaluate the outcome of surgical error: in most cases, such errors result in permanent disability and death rather than in minor and temporary disability, especially in abdominal surgery. Visceral injuries are the most recurrent adverse events in abdominal surgery, often causing a high morbidity rate and permanent disability. In the case of bowel injuries (bowel itself or blood supply), the outcome could range from a simple resection and anastomosis to a demanding procedure requiring temporary or definitive ostomies. Hemorrhage is still a concern during surgical procedures in the abdominal region, where important high-caliber vessels are present and where nerve injury can result in patient disability. Similarly important is the retention of surgical materials such as sponges and instruments, which in a wide region (eg, the abdomen) and in technically complex procedures should be imputed to both the surgeon and the operating room (OR) staff.

It is of paramount importance that surgery adopts a prevention-based problem-solving approach when facing the possibility of a technical error such as improving knowledge of the anatomy; consultation with specialists; the collaboration, implementation and standardization of evidence-based perioperative processes of care; and team training and simulations.⁵ However, because the cost of preventing adverse events entirely is prohibitive, it is important to identify those risky procedures requiring a review and improvement in precautions to ameliorate the effectiveness of efforts. Progress will also depend heavily on systems analysis, education, and the development of guidelines and standards of practice and prevention. Transformation to a culture of safety is slow and challenging, especially for surgeons, because of the fear of the professional and legal consequences. Individuals involved in technical errors should thus be viewed as valuable participants in a learning process rather than inadequate workers. The culture of safety is one in which adverse events are seen as learning opportunities to improve future patient care.

Human error is inevitable and unavoidable. The culture of safety has to reduce the risk of error. Surgeons should be able to study their errors in an open manner, use them as learning opportunities to improve health care, and make every effort to decrease them.

Case Study 10.1

Outline of the problem: Ureteral injury during colorectal surgery.

The story: A 65-year-old man with a body mass index (BMI) of 31 kg/m² presents with fatigue and weakness that started 2 weeks before admittance. His past medical history was positive for myocardial infarction treated by percutaneous stenting. Three prior severe episodes of diverticulitis were treated with antibiotics. He underwent an appendectomy during childhood. The abdomen was soft and nondistended, with mild left flank pain and bowel sounds present. Digital rectal exam was within normal limits. Routine blood samples revealed anemia (Hb 7.5 gr/dl). The patient underwent a colonoscopy that showed a mass 20 cm from the anal verge, where biopsies were carried out. The pathology report showed an undifferentiated adenocarcinoma of the colon (G3).

The surgical team decided to perform a laparoscopic left hemicolectomy. During the procedure, a medial-to-lateral approach was used. An inferior mesenteric artery was clipped at its origin using clips. The splenic flexure was mobilized. A colon dissection from the lateral abdominal wall was then performed following Toldt’s fascia. Due to the abundant adipose tissue and recurrent episodes of diverticulitis, already known from the past medical history, the dissection of the descending colon was extremely difficult and bleeding was excessive compared with a usual dissection. The wrong plane of dissection and bleeding led to the nondetection of the left ureter, which was then encountered and accidentally cut, with the advanced bipolar instrument. The surgeon decided to call a urologist. The laparoscopic procedure was converted into an open approach and an end-to-end anastomosis of the 2 ureteral stumps was performed with single stitches over a double J stent inserted into the ureter. Colon resection and lymphadenectomy were then completed.