When the gifted hands make a mistake — Surgical errors and the urgent need to invest in patient safety
I love surgery. I always have. Growing up, I always wanted to be a surgeon. I am not sure if it was the movies or the society that influenced me the most but doctors were treated special, and surgeons especially were treated like superheroes. Patients in their most vulnerable times come to surgeons and entrust their wellbeing. Below the surgeon’s sharp scalpel lies hopes, dreams, feelings, and families of people. When someone successfully performs a life-saving procedure with such a high stake, they are raised to superhuman status. This perceived status comes with a curse, the confirmation bias against mistakes.
Two years back we started Scalpel Ltd to improve patient safety in surgery. Since then our team spent every minute on building tools that reduce the chance of preventable errors in surgery. Along the way, we have learned a lot about why things go wrong in surgery, why the current solutions don’t work, and how can we fix it. This post shares some of those lessons.
A routine operation — but
It was just another busy day at the hospital for Prof James (names are changed). He already performed three minor procedures, assisted a major surgery, and was getting ready for his fourth procedure of the day. Outside the operating room, he met Kate, a 38 years young woman who was diagnosed with a large cyst in her left ovary. It was going to be a routine operation, something which Prof James had performed many times before. The scrub nurse checked her consent, anaesthetist took all the safety steps, and Prof James started the procedure.
One hour into the operation, he carefully removed the fat and tissue layers before making a swift cut into the right ovary. In a scooping motion, he removed the ovary out with the help of his residents. Everything went fine and, Kate was discharged the next day. Two years later, she was readmitted into ICU with severe pain. On performing an MRI, they realised a wrong-site surgery was performed previously. Instead of the affected left ovary, the patient’s right ovary was removed.
It was a catastrophic mistake! She was informed of the error. Eventually, her left ovary was also removed. Preventable adverse events…