HOW TO AVOID THE ‘SEVEN DEADLY SINS OF SURGERY’
Roger Kirby, The Prostate Centre, 32 Wimpole Street, London W1G 8GT, UK. e-mail: firstname.lastname@example.org, email@example.com
Increasingly, especially as surgeons, we live in a world where the hue and cry resulting from one single untoward incident can drown out the plaudits that ought to be due for literally thousands of cases that have gone smoothly. As a result, it is essential for each and every one of us to try by every means possible to avoid medical accidents, errors and untoward incidents. And when they do occur, we need to deal with their aftermath calmly and professionally.
Looking back over seven decades of combined experience in urological surgery, we thought it might be useful to consider the seven key lessons (mainly learned the hard way) in an attempt to help others avoid falling into the traps that lurk in wait for the unwary.
1. POOR COMMUNICATION
As surgeons, our job often involves breaking difficult news to patients. The way this is done is critical. It has aptly been said that if you break bad news well, the patient will never forget you; if you break it badly they will never forgive you.
Informed consent before any surgical procedure, carefully delivered and recorded, is vital. Remember it is negligent of a doctor not to give his or her patient enough information about the risks of a given procedure. Currently, of course, no definition exists of exactly how much information needs to be given. However, the greater the incidence of a complication, and the more severe it is, the stronger is the case that it should have been discussed before the operation. Detailed information sheets documenting all the downsides can be extremely helpful in this context.
In particular, when things have gone wrong a clear, honest and sympathetic explanation to the patient and his or her relatives, with follow-up meetings, can avoid months, if not years, of anxiety-inducing litigation.
The increased focus on teaching these non-technical skills aims to improve standards of communication . The launch of the BAUS national simulation program, SIMULATE, should achieve standardisation of education in technical and non-technical skills for urological trainees . To our knowledge it is the first of its kind for any specialty. The principle is clear: ‘practise safely but not on your patients’.
Modern technology and imaging have made the right diagnosis less difficult to establish than previously. One problem, though, arises from the fact that once a diagnosis has been decided upon, the die is to some extent cast, and it is quite difficult to change tack, even if the facts do not quite fit the case.
In the field of Crew Resource Management (CRM) in the airline industry, it is known that when faced with an emergency, pilots create a ‘mental model’ to help them deal with the situation [3,4]. There is often a disconnect between what the pilot believes, and what there is to know from the instruments and from the co-pilot's knowledge, as happened recently when a European Airbus stalled and plunged into the Atlantic when the speed indicators froze.
A similar failure to appreciate what is really happening may arise in the operating theatre. If advice from the team, including the assistant, the anaesthetist, the scrub nurse and even the medical student is factored in, it can sometimes help to avoid a fatal error being made. An operation with ‘unusual anatomy’ often suggests that a surgeon is in the wrong tissue plane or place.
3. MEDICATION ERRORS
These can easily happen, sometimes with disastrous consequences. The incorrect dose of insulin, morphine or chemotherapy, unchecked local anaesthetic injections and giving antibiotics to allergic patients can all be lethal; and doctors' handwriting is not always clear. The wrong patient may be prescribed the wrong medication.
A mistake of omission rather than commission is to fail to stop the anti-platelet drug clopidogrel (PlavixTM) 10 days or more before surgery. A cross-checking mentality is of paramount importance in the modern practice of medicine.
4. WRONG SITE/SIDE SURGERY
Removal of the wrong kidney, as happened a few years ago in Wales , resulted in the demise of the patient and provoked a media storm. Careful checking of the records, making absolutely certain that this is the correct record of the correct patient, marking the side and site to be operated upon, and written, informed consent taken personally by the operating surgeon should prevent a recurrence of this scenario.
With the arrival of the Picture Archiving and Communications System (PACS) in most operating theatres there is also no excuse for not having the images in front of you at all times [6–8]. The WHO checklist will should minimise these ‘never’ events even further.
5. SERIOUS UNTOWARD INCIDENTS
The manner in which a serious untoward incident is dealt with can have long-term emotional, professional and financial consequences for both patient and doctor. Most patients are aware that accidents can and do happen and that no doctor comes to work intending to harm a patient. A sympathetically delivered apology, with a frank and honest explanation of the circumstances and their consequences is vital. A genuine declaration that the episode will be investigated and analysed and the ‘lessons will be learnt’, not just by the individual involved, but by the entire team, and the Institution, never goes amiss [9–12].
If the media do begin to take an unwelcome interest in the case, it is vital to have one well-informed spokesman to give concise, honest information and not to allow individual members of the team to speak to journalists ad hoc and give ‘their side of the story’.
6. CONFLICTS WITH COLLEAGUES
Surgery is a highly competitive specialty, and many surgeons have alpha-1 type personalities. Not surprisingly, therefore, inter-personal rivalries develop and personality clashes occur. If these are not recognised and dealt with promptly, they can impair the functioning of the entire team and define the atmosphere in the department.
The negativity created can endanger patient care and make everyone's working life unpleasant. Insight to recognise that there is a problem followed by a meeting to bring these issues out into the open can frequently resolve the situation, often with surprising ease .
7. SUCCUMBING TO STRESS
It goes without saying that surgery can be a stressful occupation, especially when things go wrong. Different people find different ways of dealing with this, but quite often it is internalised and the archetypal British ‘stiff upper lip’ comes into play. The resulting inner turmoil can lead to strained relationships at home and inter-personal difficulties at work, with some resorting to alcohol, in more than healthy quantities, as a ‘stress-buster’.
At work, a key maxim is always to stay ‘in control’ and professional. Losing your temper with patients, managers or colleagues is potentially disastrous, and always regretted in the cool clear light of day.
A career in surgery can be both fascinating and rewarding, but at times challenging. The medical profession has a habit of focusing on the positive and brushing aside the negative. However, Society is moving in the opposite direction, as ‘good news does not sell newspapers’. Being aware of the traps and hazards that lurk just beneath the surface can help us all steer clear of them [14,15]. If the ‘seven deadly sins of surgery’ are to be avoided over an entire career, we need to be constantly on our guard.
P.D. acknowledges support from the National Institute for Health Research Biomedical Research Centre and the Medical Research Council Centre for Transplantation. He is supported by the BAUS national simulation program and project grants from the School of Surgery, London Deanery and Olympus.
CONFLICTS OF INTEREST
None to declare.