Current challenges and future perspectives for patient safety in surgery

Abstract

As surgeons, we are arguably practitioners of one of themost entitled, rewarded and rewarding occupations inthe world. We are privileged to meet and interact withpreviously unknown individuals on a most intimate andpersonal level, and to make a positive difference at someof the worst times in their lives. We eventually knowthese people in ways they cannot know themselves, andwe are able help them in ways they cannot help them-selves. We are empowered to the completely legal actionof putting a knife to work in a human body. With properindication and distinguished technical skills, our surgicalblade can provide a cure for acute and chronic ailmentsin the most vulnerable population of human beings. Inreturn, our patients reward us with their unlimited trustin our knowledge, skills, and ability to deliver them torestored health and an improved quality of life. Unfortu-nately, we fail to restore our patients’ health and qualityof life more often than we appreciate. While all physi-cians take the Hippocratic Oath to abstain from doingharm (”Primum non nocere”), our patients are frequentlycaught in the ‘friendly fire’ of surgical care – health careproviders causing unintentional harm when their onlyintent was to help [1,2].Interestingly, adverse events resulting from surgical in-terventions are actually more frequently related to errorsoccurring before or after the procedure than by technicalmistakes by a surgical blade ‘gone wrong’. These include(i) breakdown in communication within and amongstthe surgical team, care providers, patients and their fam-ilies; (ii) delay in diagnosis or failure to diagnose; and(iii) delay in treatment or failure to treat [3-5]. On adaily basis, surgeons must adjudicate challenges thatreach far beyond pure technical aspects – the decisionof initiating appropriate and timely surgical care,weighed against the risk of providing delayed or negli-gent care by rather choosing observation and/or non-operative treatment. This narrow margin represents thefoundation of a surgeon’seternal‘moment of truth’(“to cut or not to cut”) which could be a crucial turningpoint in the long-term future of our patients.How can patients be sure that their surgeon is compe-tent, knowledgeable, and well trained? How can patientsbe sure that the proposed treatment modality or surgicalprocedure represents the optimal treatment of choice?How can patients be sure that surgeons are singularlyincentivized to provide only high quality and safe surgi-cal care, independent of other metrics of success, includ-ing entrenched financial interests? How can patients besure that the surgical team is dominated by an immut-able ‘culture of patient safety‘ with full buy-in by allmembers of the team? How can patients be sure thatthey will not be exposed to the learning curve of a newprocedure or a young surgeon in training?Ironically, the high standard of regulatory compliance-mandated patient safety protocols in the United Statesemanates from decades of work by lawyers and patientadvocacy groups, not from physician-driven initiative. Itis time to end this historic negligence. It is time forsurgeons to direct and own patient safety as a ‘surgicalresponsibility’.More than 200 million surgeries are performed world-wide each year [6]. Any patient admitted to a hospital toundergo a surgical procedure should rightfully expect tobe better off after the intervention than before. However,recent reports reveal that adverse event rates for surgicalconditions remain unacceptably high, despite multiplenationwide and global patient safety initiatives overthepastdecade[7].Theseincludethe’100,000 LivesCampaign’ (2005/2006) and subsequent ‘5 Million LivesCampaign’ (2007/2008) by the Institute for HealthcareImprovement (IHI), the ‘Surgical Care ImprovementProject’ (2006) and ‘Universal Protocol’ (2009) by the JointCommission, and the WHO ‘Safe Surgery Saves Lives’campaign accompanied by the global implementation ofthe WHO surgical safety checklist (2009) [8-13].Many of the current limitations to the creation of aglobally recognized and consistently practiced ‘culture of