Techniques aren’t everything: Why conscientious well-trained surgeons make mistakes?

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 & N. Francis Nader.Francis@ydh.nhs.uk