Chapter 1 From Error to Perfection: The Process of Surgical Maturation
SURGICAL ERRORS
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
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.
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
THEORIES OF HUMAN PERFORMANCE
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.
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.
![image](https://i0.wp.com/basicmedicalkey.com/wp-content/uploads/2017/06/B9781416029519500086_gr2.jpg?w=960)
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.)
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.”
THE IMPORTANCE OF ERROR RESPONSE
So, I Made a Mistake …
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.”
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