In an environment like the operating room, where mistakes have life-threatening consequences, the margin for error is slim. Not learning from or repeating errors is not acceptable. Yet, the same mistakes are repeated on a day-to-day basis. Extensive research examining a 20-year period found that nearly 4,000 surgical errors called “never events,” errors that should never happen, occur each year in the United States alone. Never events can include operating on the wrong body part, leaving a foreign object inside a patient’s body after an operation, or performing the wrong procedure. These errors have dire consequences for the patient, surgeon, and hospital system alike and jeopardize the necessary patient-provider trust that is required to produce successful health outcomes.
To understand the global scope of surgical errors, one does not have to look far to find examples of a surgeon’s and patient’s worst nightmare. In South Korea, a case from 2016 accused surgeons at private clinics of assigning unqualified medical professionals to perform procedures that led to the death of the patient. In Germany, numerous instances of incorrect handling of biological material, wrong treatment, and misplaced medical equipment have been reported to health insurers.
It would be easy to blame the surgeons, nurses, and hospitals for errors. However, I will argue that the caregivers are not to blame. Awareness of their challenges, commitment to change and financial investment into tools and systems for surgeons and patients needs to happen on hospital, regulatory and team levels.
To understand why errors continue to happen, one needs to look at the structural, organizational, and technological stressors that surgeons face. These challenges are exacerbated by the COVID-19 pandemic, which has created additional problems in workload and volatility. Surgeons are working in high-intensity environments with still very little automation and investment software support systems. At the same time, many hospitals are dealing with staffing shortages for already overburdened health professionals, leaving some US states to declare an emergency. As such, hospital workforces are being forced to ration their care, dedicate less time to each patient, and even turn away patients needing special care like trauma surgery. Additionally, with many elective surgeries on hold, surgeons are experiencing a higher volume of complex cases that demand more attention and time. These interruptions on top of an ever-growing patient backlog have formed a suboptimal system that reduces the overall efficiency of the surgical suite and creates undue risk to patient safety. When there are only rudimentary systems in place to support surgical teams from preventing mistakes, it is clear that patient safety decreases and overall risk rises.
However, as other researchers have noted, humanity has successfully tackled risks of commercial airlines or other high-acuity areas where lives are at stake to minimal levels.
After more than a decade in the healthcare and surgical technology field, I have found that a key component to creating a safer and smarter operating room can be found in a platform that supports the surgeon and team during the procedure, and makes the data available for review after the procedure. Through this approach, we can guide and examine surgical performance to negate potential errors before they appear – a kind of “digital safety net for surgeons”.
This can for example be done by automated warning systems to avoid mistakes common in certain procedural steps during the procedure, a kind of “blind spot assistant” for surgery, Another important tool are post-surgery video-based assessment (VBA) platforms that encourage increased awareness and promote learning.
The merits of video-based programs in surgery are many, here are a few of the most important considerations:
- Observation: By creating an environment where healthcare professionals are provided with guidance and VBA awareness tools. Surgeons will in critical situations be reminded to double-check their actions, which reduces the likelihood of error.
- Attribution: Video-based tools can help surgeons attribute errors to specific actions. This is not to say observational techniques are punitive by any means. In fact, the ability to rewatch and examine footage can play a significant role in organizational and individual learning process as they can identify mistakes and learn how to mitigate them moving forward.
- Review: Video-based tools allow doctors to review their footage and compare with best practice. This helps develop and optimize their operating room environment and keep their patients safe. It can also be helpful to review footage of the procedure for understanding any post-surgery complications that the patient may be experiencing.
For surgeons to practice at the top of their capabilities and reduce the surgical errors that harm patients, health and hospital systems must invest in measurable ways to support, monitor and assess performance.
To learn more about how adopting a methodological approach can create a digital safety net for surgeons and improve patient outcomes, be sure to tune into my presentation at the Future Surgery Show on November 10. You can register for the event here.