How to Avoid the Seven Deadly Sins of Surgery

INTRODUCTION HOW TO AVOID THE ‘ SEVEN DEADLY SINS OF SURGERY’ Roger Kirby * , Ben Challacombe *† , Prokar Dasgupta *† and Increasingly, especially as surgeons, we live ‡ † in a world where the hue and cry resulting John M. Fitzpatrick – * The Prostate Centre , and Department of Urology, MRC from one single untoward incident can Centre for Transplantation, Guy ’ s Hospital, King ’ s College London, King ’ s Health Partners, drown out the plaudits that ought to be due London, UK , and ‡ Mater Misericordiae Hospital and University College Dublin, Dublin, Ireland for literally thousands of cases that have Accepted for publication 14 September 2011 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 to the patient and his or her relatives, with A similar failure to appreciate what is really aftermath calmly and professionally. follow-up meetings, can avoid months, if happening may arise in the operating not years, of anxiety-inducing litigation. theatre. If advice from the team, including Looking back over seven decades of the assistant, the anaesthetist, the scrub combined experience in urological surgery, The increased focus on teaching these nurse and even the medical student is we thought it might be useful to consider non-technical skills aims to improve factored in, it can sometimes help to avoid a the seven key lessons (mainly learned the standards of communication [ 1 ] . The launch fatal error being made. An operation with hard way) in an attempt to help others of the BAUS national simulation program, ‘ unusual anatomy ’ often suggests that a avoid falling into the traps that lurk in wait SIMULATE, should achieve standardisation of surgeon is in the wrong tissue plane or for the unwary. education in technical and non-technical place. skills for urological trainees [ 2 ] . To our knowledge it is the fi rst of its kind for any 1. POOR COMMUNICATION specialty. The principle is clear: ‘ practise 3. MEDICATION ERRORS safely but not on your patients ’. As surgeons, our job often involves breaking These can easily happen, sometimes with diffi cult news to patients. The way this is disastrous consequences. The incorrect dose done is critical. It has aptly been said that if 2. MISDIAGNOSIS of insulin, morphine or chemotherapy, you break bad news well, the patient will unchecked local anaesthetic injections and never forget you; if you break it badly they Modern technology and imaging have made giving antibiotics to allergic patients can all will never forgive you. the right diagnosis less diffi cult to establish be lethal; and doctors ’ handwriting is not than previously. One problem, though, arises always clear. The wrong patient may be Informed consent before any surgical from the fact that once a diagnosis has prescribed the wrong medication. procedure, carefully delivered and recorded, been decided upon, the die is to some is vital. Remember it is negligent of a doctor extent cast, and it is quite diffi cult to A mistake of omission rather than not to give his or her patient enough change tack, even if the facts do not quite commission is to fail to stop the anti- information about the risks of a given fi t the case. platelet drug clopidogrel (PlavixTM ) 10 days procedure. Currently, of course, no defi nition or more before surgery. A cross-checking exists of exactly how much information In the fi eld of Crew Resource Management mentality is of paramount importance in the needs to be given. However, the greater the (CRM) in the airline industry, it is known modern practice of medicine. incidence of a complication, and the more that when faced with an emergency, pilots severe it is, the stronger is the case that it create a ‘ mental model ’ to help them deal should have been discussed before the with the situation [ 3,4 ] . There is often a 4. WRONG SITE/SIDE SURGERY operation. Detailed information sheets disconnect between what the pilot believes, documenting all the downsides can be and what there is to know from the Removal of the wrong kidney, as happened extremely helpful in this context. instruments and from the co-pilot ’ s a few years ago in Wales [ 5 ] , resulted in the knowledge, as happened recently when a demise of the patient and provoked a media In particular, when things have gone wrong European Airbus stalled and plunged into storm. Careful checking of the records, a clear, honest and sympathetic explanation the Atlantic when the speed indicators froze. making absolutely certain that this is the

correct record of the correct patient, frequently resolve the situation, often with evaluate NOTSS (Non-Technical Skills for marking the side and site to be operated surprising ease [ 13 ] . Surgeons) for assessing trainees ’ upon, and written, informed consent taken non-technical performance in the personally by the operating surgeon should operating theatre . Br J Surg 2 0 1 1 ; 98 : 7. SUCCUMBING TO STRESS prevent a recurrence of this scenario. 1010 – 20 2 Ahmed K , Abboudi M , Challacombe B , It goes without saying that surgery can be a With the arrival of the Picture Archiving and Khan MS , Dasgupta P . Educational stressful occupation, especially when things Communications System (PACS) in most research in urology: current status and go wrong. Different people fi nd different operating theatres there is also no excuse future challenges . BJU Int 2 0 1 1 ; 107 : ways of dealing with this, but quite often it for not having the images in front of you at 1872 – 3 is internalised and the archetypal British all times [ 6 – 8 ] . The WHO checklist will 3 Helmreich RL . On error management: ‘ stiff upper lip ’ comes into play. The should minimise these ‘ never ’ events even lessons from aviation . BMJ 2000 ; 320 : resulting inner turmoil can lead to strained further. 781 – 5 relationships at home and inter-personal 4 O ’ Connor P , Campbell J , Newon J diffi culties at work, with some resorting to et al . Crew Resource management alcohol, in more than healthy quantities, as 5. SERIOUS UNTOWARD INCIDENTS training effectiveness: a meta-analysis a ‘ stress-buster ’. and some critical needs . Int Aviat The manner in which a serious untoward Psychol 2008 ; 18 : 353 – 68 At work, a key maxim is always to stay ‘ in incident is dealt with can have long-term 5 BBC News. Two suspended over op control ’ and professional. Losing your emotional, professional and fi nancial blunder . Available at: http://news.bbc. temper with patients, managers or consequences for both patient and doctor. co.uk/1/hi/wales/3424847.stm . Accessed colleagues is potentially disastrous, and Most patients are aware that accidents can November 2011 always regretted in the cool clear light of and do happen and that no doctor comes to 6 Haynes AB , Weiser TG , Berry WR et al . day. work intending to harm a patient. A Safe Surgery Saves Lives Study Group. A sympathetically delivered apology, with a surgical safety checklist to reduce A career in surgery can be both fascinating frank and honest explanation of the morbidity and mortality in a global and rewarding, but at times challenging. circumstances and their consequences is population . N Engl J Med 2009 ; 360 : The medical profession has a habit of vital. A genuine declaration that the episode 491 – 9 focusing on the positive and brushing will be investigated and analysed and the 7 de Vries EN , Prins HA , Crolla RM aside the negative. However, Society is ‘ lessons will be learnt ’ , not just by the et al . SURPASS Collaborative Group. moving in the opposite direction, as ‘ good individual involved, but by the entire team, Effect of a comprehensive surgical news does not sell newspapers ’. Being aware and the Institution, never goes amiss [ 9 – 12 ] . safety system on patient outcomes . of the traps and hazards that lurk just N Engl J Med 2 0 1 0 ; 363 : 1928 – beneath the surface can help us all steer If the media do begin to take an unwelcome 37 clear of them [ 14,15 ] . If the ‘ seven deadly interest in the case, it is vital to have one 8 Kwann M , Studdert DM , Zinner MJ sins of surgery ’ are to be avoided over an well-informed spokesman to give concise, et al . Incidence, patterns, and prevention entire career, we need to be constantly on honest information and not to allow of wrong-site surgery . Arch Surg 2006 ; our guard. individual members of the team to speak to 141 : 353 – 8 journalists ad hoc and give ‘ their side of the 9 O ’ Connor E , Coates HM , Yardley IE , story ’. ACKNOWLEDGEMENTS Wu AW . Disclosure of patient safety incidents: a comprehensive review . P.D. acknowledges support from the Int J Qual Health Care 2 0 1 0 ; 22 : 371 – 6. CONFLICTS WITH COLLEAGUES National Institute for Health Research 9 Biomedical Research Centre and the Medical 10 Manser T , Staender S . Aftermath of an Surgery is a highly competitive specialty, Research Council Centre for Transplantation. adverse event: supporting health care and many surgeons have alpha-1 type He is supported by the BAUS national professionals to meet patient personalities. Not surprisingly, therefore, simulation program and project grants from expectations through open disclosure . inter-personal rivalries develop and the School of Surgery, London Deanery and Acta Anaesthesiol Scand 2005 ; 49 : personality clashes occur. If these are not Olympus. 728 – 34 recognised and dealt with promptly, they 11 Pace WD , Staton EW . Improving the can impair the functioning of the entire disclosure of medical incidents . BMJ CONFLICTS OF INTEREST team and defi ne the atmosphere in the 2 0 1 1 ; 343 : d4340 department. 12 Iedema R , Allen S , Britton K None to declare. et al . Patients ’ and family members ’ The negativity created can endanger patient views on how clinicians enact and care and make everyone ’ s working life REFERENCES how they should enact incident unpleasant. Insight to recognise that there is disclosure: the ‘ 100 patient stories ’ a problem followed by a meeting to bring 1 Crossley J , Marriott J , Purdie H , Beard qualitative study . BMJ 2 0 1 1 ; 343 : these issues out into the open can JD . Prospective observational study to d4423

13 Lee L , Berger DH , Awad SS , Brandt case of the boiled bladder – or, how to ML , Martinez G , Brunicardi FC . avoid medical errors . BJU Int 2 0 1 0 ; 106 : Conﬂ ict resolution: practical principles 299 – 300 for surgeons . World J Surg 2008 ; 32 : 2331 – 5 Correspondence: Roger Kirby, The Prostate 14 Kirby RS . Learning the lessons from Centre, 32 Wimpole Street, London medical errors . BJU Int 2003 ; 92 : 4 – W1G 8GT, UK. 5 e-mail: [email protected] , 15 Kirby RS , Dasgupta P , Beacock C . The [email protected]