Surgical Risks and Blunders: Why Do Things Go Wrong?
This is not as glib a question as it sounds. Like flying a jumbo jet, surgery is an inherently high-risk activity: while this comparison is often drawn, it is not strictly accurate. Conducting surgery is akin to piloting a very fast plane (say, an F-16), with a single passenger who signed a consent form just before take-off, authorising the captain to do some really nifty in-flight aerobatics.
The comparison between surgery and flight was used over the past decade in some valuable research into operative risk from Professor De Leval and colleagues at Great Ormond Street (GOS). The GOS studies evaluated a number of operation series, and found that the major operative incidents reported rarely happened without warning. Most were preceded in previous operations by procedural breaches, other minor systemic errors, and poor communication between members of the operating team, leading on occasion to ‘near misses’. These surgical ‘near misses’ were incidents in which things nearly went disastrously wrong for the patient, but in which the situation was pulled around. Professor De Leval suggested that the sort of risk stratification techniques that airlines use routinely could (and should) be utilised by surgical teams. It would seem that whilst dramatic errors like having the wrong kidney removed do occasionally happen, they are far more likely to be the result of substandard communications and record keeping than of the consultant turning up drunk.
Professor De Leval’s findings and recommendations, in our view, deserve a much wider audience, and it is pleasing to note that Sir Liam Donaldson has recently suggested that regulatory methods used within the civil aviation industry should be introduced into the NHS. Regular reviews of the performance not of individual surgeons but of the surgical practice of acute Trusts, and even assessing the way in which records are kept and inter-departmental transfers of patients are arranged, might well lower risks to patients considerably.
Contact
Angelina Rigby Head of Clinical Negligence
Steve Duddell Partner
Nye Moloney Trainee Legal Executive
Mary Smith Paralegal
Jane Beresford-Huey Assistant
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