Who Is to Blame?

The landmark report, To Err Is Human, from the Institute of Medicine (IOM) published in 1999¹ spurred enormous attention and focus on patient safety. Initiatives to reduce the number of preventable deaths from medical errors have received widespread awareness, both in the medical literature and in the lay press.¹ Five years after the IOM report, Leape and Berwick published a grim account on the lack of progress that the medical community has made in enhancing patient safety.² These authors urged the medical community to take ownership in the matter and said, “We will not become safe until we chose to become safe.”²

Despite this pessimistic view, a few reports of improvement have been published over the last several years. Brennen³ demonstrated this more optimistic viewpoint. He showed that the rate of injury in medical care in the 1970s was 4.6% in the state of California, but by 1984, New York’s rate declined to 3.7%, and by 1992, Colorado’s and Utah’s rates fell to 2.9%. In addition, he reiterated what has long been known: that major operative procedures in cardiac surgery and neurosurgery have shown significant reductions in complication rates and overall mortality over the last several decades.³

Although at times met by some degree of animosity, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the Agency for Health Care Research and Quality have certainly taken ownership in developing policies to reduce medical errors on a national level. They have mandated error reduction policies in the operating room such as preoperative checklists, surgical marking for “correct side and correct patient,” and the obligatory “timeout” to enhance communication in the operating room. These JCAHO policies are touted to minimize errors by enhancing communication between anesthesia, nursing, and surgical staff.

Taking Ownership

At the individual practitioner level, significant room for improvement still exists because we have not uniformly “chosen to become safe.” This is because the surgical approach has historically been more reactive than proactive. Although we, as surgeons, have a strong history of dissecting our own craft, evaluating successes and reviewing flaws in forums such as morbidity and mortality (M&M) conferences, we have not acted cohesively.

We all know that the surgical M&M conference—in which surgeons tend to be honest and open about mistakes and propose to learn from those mistakes—has been hailed as the best educational experience for all trainees. However, this forum can be disorganized and happenstance and could become more word of mouth than anything reportable. Indeed, many other fields of medicine do not even participate in a weekly M&M conference. Moreover, even when we know that errors are definable and predictable in given operations, our ability to educate and train in error reduction has fallen short. Passionate discussions that may surface in each hospital’s lecture hall are often forgotten by the next week.

Why have we not developed a national registry to report errors that are discovered in these surgical think tanks? Why do we not have a monthly journal dedicated solely to exploring these mistakes to better our field? Many barriers exist to open discussion of surgical errors at a national level, not the least of which is the medicolegal climate.

Whereas a unified approach at error reduction seems insurmountable, the current intense focus on patient safety should drive this initiative. We cannot accept anything less than the effort toward perfection. As Deming stated, “if we had to live with 99.9%, we would have: two unsafe plane landings per day at O’Hare, 16,000 pieces of lost mail every hour, 32,000 bank checks deducted from the wrong bank account every hour” (Deming, personal communication, November 1987). Our sophisticated culture demands this effort.

It is time for the individual surgeon to take ownership in this matter. This textbook focuses exclusively upon the individual in an attempt to improve error reduction at both the cognitive and the technical levels. We also hope to affect the future of surgical education by exposing practical ways to teach not just the surgical resident but also more experienced surgeons on the approach to error reduction on a daily basis. We hope that by looking carefully at flaws in cognitive thought processes or technical errors that are preventable, the opportunities for improvement at the practicing physician level will become obvious.

The Paralysis of Fear

Leape⁴ talked about the powerful fear of error (Fig. 1-1). This trilogy is encompassed by (1) the fear of embarrassment by colleagues, (2) the fear of patient reaction to errors, and (3) the fear of litigation. It has seemingly paralyzed our ability to proactively approach error reduction. Moreover, these collective fears are certainly the reasons why we have not uniformly shared and/or published our complications.

Figure 1-1 Lucian Leape.

(Courtesy of Lucian L. Leape, MD.)

First, we loathe exposing our ignorance or technical failures to our fellow surgeons and medical colleagues. To become the talk of the surgeon’s lounge over a recent operative failure is our worst nightmare.

Second, we face the fear of patient reaction to the mistake we made. It is natural to be uncomfortable talking to patients after mistakes and errors have occurred. Even more distressing is working in an academic health center where resident training is conducted and a mistake occurs. Patients may commonly ask, “What is the resident’s role in my operation and in my care?” And if a mistake occurs, the patient may ask, “Is this is an error caused by the resident?” or “Is this a training error?”

Lastly, the prevailing fear of litigation may have become the most dominant stagnating force we face. The “MALPRACTICE MACHINE” is on our radar screen daily and has certainly been popularized on the Internet at such sites as “fightingforyou.com.” One can find common headlines such as “Surgical errors are among the most carefully regarded secrets in the medical industry.”

The Paradox

Although it is a formidable, some say impossible, task, we cannot be frozen by inaction in an attempt to strive for perfection. Leape described this complex conflict: “the paradox … that although the standard of medical practice is perfection—error-free patient care—all physicians recognize that mistakes are inevitable.”²

We know we are all human, but this is not an explanation accepted by the media, the public, the insurance companies, or malpractice lawyers.

Knowledge, Rule, and Skill-Based Performances

To understand how human errors occur, we must first understand the theories behind human performance. Rasmussen and Jensen⁵ have written extensively on the concepts of human performance, which they divide into three types: (1) knowledge-based, (2) rule-based, and (3) skill-based.⁵ First, knowledge-based performance occurs when we act on novel thought during new situations (e.g., this is the intern’s life—all operations are new to them and all patient scenarios on the wards are unique to them). Second, ruled-based performance happens when we develop solutions to problems dictated by stored rules—patterns of behavior that occur based upon specific situations (e.g., when we are presented with the unmistakable, discreet areolar plane while mobilizing a right colon, we know our dissection can proceed expediently and safely). Third, skilled-based performance refers to patterns of thought and action that are unconscious or preprogrammed. These are certainly the most common, routine performances that we carry on a daily basis (e.g., driving a car on the same roads daily to work or an experienced surgeon performing his or her 500th inguinal hernia repair).

Errors in Human Performance

Reason⁶ and Rasmussen and Jensen⁵ have classified errors that can occur in each of these performance categories. Knowledge-based errors happen when there is simply a lack of experience or knowledge or a misinterpretation of the problem. These commonly occur to either the inexperienced surgeon or trainee who is on the steep end of the learning curve and who encounters a novel clinical situation. It is these knowledge-based errors that we hope this book will clearly illuminate so that we can all avoid them.

Rule-based errors are categorized as misapplied expertise. The wrong rule is chosen during problem solving. This is commonly related to a misperception of the situation or misapplication of a “rule” that is understood but not used correctly.

Lastly, skill-based errors are referred to as “slips.” They occur when there is an unusual break in the routine or lack of an additional check (or “time out”) so that we, for example, operate on the wrong leg or on the wrong patient or leave a malleable in the patient after laparotomy. Interestingly, these are more likely to occur with physiologic conditions such as fatigue and psychological interferences such as boredom or frustration.

Which errors are the most common? Actually, slips, the skill-based errors, are the most common because most of our daily mental functioning is automatic. However, the rate of error is higher with knowledge-based errors because these typically occur on the steep part of the learning curve.⁶ This book’s aim is to illuminate and expose pitfalls and errors at all three levels and to change our performance in surgery by focusing training and policy on error reduction.

Perceptual Errors in the Operating Room: Heuristics

Understanding the etiology and mechanism for technical errors that occur in operative procedures is a generalized theme throughout this textbook. In a highly referenced and quoted article, Way and coworkers⁷ studied patients with major bile duct injuries during laparoscopic cholecystectomy in order to determine the cause of the errors. They classified each injury into three different groups: (1) knowledge and decision making errors, (2) a lack of technical skills, and (3) errors of perceptual input or a misperception of the anatomy. The majority of the injuries were of the third type. This variety of error mechanism is based on the principle of heuristics. Heuristics are normal, rapid, subconscious responses that work based upon subjective or illusory contours or shapes. If you look at an example such as the Kanizsa triangle (Fig. 1-2), you may think you are seeing a white triangle surrounded by dark circles. However, a white triangle is NOT actually present, your mind merely constructs it from the backdrop of the circles. The white triangle also appears to be brighter than the surrounding area, but in fact, it is not.

Figure 1-2 Kanizsa triangle.

(From Way LW, Stewart L, Gantert W, et al. Causes and prevention of laparoscopic bile duct injuries. Ann Surg 2003;237:460–469.)

As surgeons, we have all encountered heuristics in some way or another. Interestingly, it is inherent in the way our brain functions. Our brain is wired to use the first information that comes to mind in order to understand or comprehend the world.

Heuristics are important to recognize, especially in the setting of the operating room. As we proceed through a common operation and visualize globally what the operative field looks like, we may have a tendency to become complacent about what we see. Humans prefer common patterns and familiarity, especially in the operating room. Therefore, we seek out what we already know from memory. Making a rapid decision based only on misrepresented visual input could get us in trouble. This book will hopefully open our minds to the hidden anatomy that we must all be cognizant of to prevent technical errors.

As Reason⁶ described, “the price we pay for this automatic processing of information is that perceptions, memories, thoughts, and actions have a tendency to err in the direction of the familiar and the expected.”

So, I Made a Mistake …

Although it does seem that “to err is human” and much of our abilities to make errors is a constant experience throughout existence, our responses to mistakes are quite individual. First, some of us simply deny that the error even occurred by constantly deflecting the situation and taking no ownership of the error itself. Second, others may be overcome with fear after making an error such that subsequent similar operations are performed with the sole focus on not making a mistake instead of performing the operation correctly. This is a disaster in the setting of oncologic surgery, in which inadequate resections are performed overshadowed by the constant fear of trying to avoid ureteral or vascular injuries. Third, some of us are overcome with passive acceptance. This is the surgeon who believes that mistakes will always occur no matter what we do, and therefore, there is no necessity for change or intervention. Finally, there are those who are deeply analytical. After we make a mistake, we are self-critical, analyze the literature, review videos, and channel all of our energy into self-improvement to minimize the chances of that error occurring again.

It turns out that our response to making an error is one of the most important reactions we make in our career. In residency, we may remember those residents who did not succeed. What was it about them that made them fail? Bosk at the University of Pennsylvania studied this and discovered that failure is related to these responses to making mistakes. Bosk studied the University of Pennsylvania neurosurgery program and found that the failures were residents with passive acceptance, who believe that mistakes will rarely occur or that “bad outcomes [have occurred] due to things outside my control.”⁸ Conversely, the successful neurosurgery resident was the analytical surgeon who admits that she or he makes terrible mistakes, “plenty of mistakes,” and “is driven to eliminate failure.”