How to Avoid Surgical Errors

Don Sadler

It’s probably safe to say that every member of the perioperative staff strives for perfection in the OR. However, every member of the OR staff is a human being, which means that surgical errors do unfortunately occur.

Major Errors and Never Events

Major surgical errors are referred to as “never events.” According to Linda Groah, MSN, RN, CNOR, NEA-BC, FAAN, the Executive Director and CEO of the Association of periOperative Registered Nurses (AORN), a few of the most common never events are:

• retained foreign objects or surgical items (such as a sponge or medical instrument) that are left in the patient’s body after the procedure is finished;

• wrong-patient, wrong-side and wrong-procedure surgeries;

• nerve damage that’s usually related to positioning issues; and

• anesthesia errors.

Especially prevalent are wrong-patient, wrong-side and wrong-procedure surgeries, she says.

“The Joint Commission reports that 40 of these occur in the U.S. every week,” Groah explains.

“This error is not common, although it still happens far too frequently,” says Tejal K. Gandhi, MD, MPH, CPPS, the President and CEO of the National Patient Safety Foundation.

Coleen Smith, High Reliability Initiatives Director, Black Belt, for The Joint Commission Center for Transforming Healthcare, adds that wrong-patient, wrong-side and wrong-procedure surgeries are the second most-reported sentinel event to The Joint Commission.

Meanwhile, Gandhi notes that studies estimate that the error of retained foreign objects may occur in as many as one in 1,000 abdominal surgeries and one in 18,000 inpatient surgeries.

“The most reported root causes for sentinel events are a lack of leadership, human factors, poor communication, and faulty assessment,” says Smith.

She says the Center for Transforming Healthcare has identified a number of contributing factors to sentinel events, including:

• OR booking documents are not verified by office schedulers;

• time constraints during patient verification that cause staff to rush;

• ineffective hand-off communications or briefing processes;

• site mark(s) are removed during prep or covered by surgical draping;

• the surgical time out is performed without full participation;

• senior leadership is not actively engaged; and

• there is an inconsistent organizational focus on patient safety.

“The Center urges health care organizations to establish a safety culture in which staff are expected to speak up when they have a patient safety concern,” says Smith. “In addition, staff should be educated about the value of standardized processes, including the surgical time out process, and be held accountable for their role in risk reduction.”

A Culture of Safety

Groah also stresses the importance of establishing a culture of safety where staff feel comfortable reporting a near miss or error and are recognized for coming forward with information to create a safe surgical environment.

“Weaving a culture of safety into the fabric of the organization requires members of leadership to allocate resources and provide incentives or rewards for promoting the culture of safety,” says Groah. “Team training and the culture of safety promote respect and accountability among all OR team members.”

Groah attributes many surgical errors to “a lack of awareness of the next big event that could occur and cause harm or damage to patients. This includes the failure of systems and processes either by omission or commission, as well as assuming that errors ‘won’t happen here.’ ”

A lack of proper monitoring is another common cause of surgical errors, says Groah.

“This requires auditing how policies and procedures are implemented and whether the team is following evidence-based guidelines and practices,” she says. “Responding to the findings of the audit with corrective action and education, either for individual team members or for the team as a whole, is also critical.”

Major vs. Technical Errors

Gandhi makes a distinction between major errors or never events and what she calls technical errors.

“These include manual errors, like when a blood vessel gets cut inadvertently, as well as errors in judgment that delay a procedure or result in a technique being used that it not advisable, such as laparoscopic removal of a malignant organ or growth,” she says.

These incidents do not usually occur due to inexperience or a lack of skill, says Gandhi.

“In fact, one study found that they most often involve experienced surgeons but complicated cases, with systems factors usually contributing to the error,” she says.

“In another study of closed malpractice claims, it was determined that systems factors were involved in the majority of cases where patients were harmed either in surgery or in perioperative care,” Gandhi adds.

Adopting Other Industries’ Safety Practices

Some hospitals have begun adopting safety practices from airlines and the military to help prevent surgical errors. These practices include checklists, simulations/simulators and debriefings.

“Team training simulations with OR staff are very common, especially with anesthesia,” says Gandhi. “Briefings and debriefings as part of the WHO Safe Surgery Checklist and other surgery checklists are also becoming more widespread.”

“The checklist is one of several tools or initiatives to support a safe surgical environment,” says Groah. “Simulation centers are also gaining popularity – they are an excellent resource to encourage teamwork and the culture of safety.”

According to Groah, AORN has created a comprehensive surgical checklist that includes specific steps to be followed at four key surgical phases: pre-procedure check-in, sign-in, time-out, and sign-out. It includes processes that have been learned in other industries and applied to the OR in order to minimize the chances of surgical errors.

The AORN surgical checklist can be downloaded at www.aorn.org/surgicalchecklist.

“Debriefings, meanwhile, are implemented at the end of the surgical case to assess how the team performed,” Groah adds. “They assess what went well and what areas need to be improved the next time the procedure is performed.”

“We are firm believers in using practices adopted from other industries,” says Smith. “In fact, we use Robust Process Improvement (RPI) methods and tools to help organizations improve the quality and safety of health care. These include Lean, Six Sigma and other change management tools and methodologies for high reliability.”

Smith says that the Center for Transforming Healthcare recently released Oro 2.0 to assist with safe practices.

“This is an online organizational assessment with resources designed to guide hospital leadership throughout the high reliability journey,” she says. “The assessment focuses specifically on the areas of leadership commitment, safety culture and performance improvement.”

The Targeted Solutions Tool 

In 2009, the Center for Transforming Healthcare and Lifespan System in Rhode Island initiated the Safe Surgery Project. The goal was to improve safeguards in order to prevent wrong-patient, wrong-site and wrong-procedure surgeries.

“As a result of this project, several solutions were identified, resulting in the Safe Surgery Targeted Solutions Tool (TST),” says Smith.

The TST is an application that guides health care organizations through a step-by-step process to accurately measure their performance, identify barriers to excellent performance, and direct organizations to proven solutions that are customized to address their particular barriers.

The results of the Safe Surgery Project have been impressive in terms of reducing surgical errors and improving patient safety. According to Smith, the Center for Transforming Healthcare was able to help participating organizations reduce the number of cases with risks by 46 percent in the scheduling area, 63 percent in pre-op and 51 percent in the operating room.

“The center urges health care organizations to celebrate successes in reducing surgical errors and make everyone on the team aware of improvements,” says Smith.