As surgeons, we are arguably practitioners of one of the most entitled, rewarded and
rewarding occupations in the world. We are privileged to meet and interact with previously
unknown individuals on a most intimate and personal level, and to make a positive
difference at some of the worst times in their lives. We eventually know these people
in ways they cannot know themselves, and we are able help them in ways they cannot
help themselves. We are empowered to the completely legal action of putting a knife
to work in a human body. With proper indication and distinguished technical skills,
our surgical blade can provide a cure for acute and chronic ailments in the most vulnerable
population of human beings. In return, our patients reward us with their unlimited
trust in our knowledge, skills, and ability to deliver them to restored health and
an improved quality of life. Unfortunately, we fail to restore our patients’ health
and quality of life more often than we appreciate. While all physicians take the Hippocratic
Oath to abstain from doing harm (”Primum non nocere”), our patients are frequently
caught in the ‘friendly fire’ of surgical care – health care providers causing unintentional
harm when their only intent was to help [1,2].
Interestingly, adverse events resulting from surgical interventions are actually more
frequently related to errors occurring before or after the procedure than by technical
mistakes by a surgical blade ‘gone wrong’. These include (i) breakdown in communication
within and amongst the surgical team, care providers, patients and their families;
(ii) delay in diagnosis or failure to diagnose; and (iii) delay in treatment or failure
to treat [3-5]. On a daily basis, surgeons must adjudicate challenges that reach far
beyond pure technical aspects – the decision of initiating appropriate and timely
surgical care, weighed against the risk of providing delayed or negligent care by
rather choosing observation and/or non-operative treatment. This narrow margin represents
the foundation of a surgeon’s eternal ‘moment of truth’ (“to cut or not to cut”) which
could be a crucial turning point in the long-term future of our patients.
How can patients be sure that their surgeon is competent, knowledgeable, and well
trained? How can patients be sure that the proposed treatment modality or surgical
procedure represents the optimal treatment of choice? How can patients be sure that
surgeons are singularly incentivized to provide only high quality and safe surgical
care, independent of other metrics of success, including entrenched financial interests?
How can patients be sure that the surgical team is dominated by an immutable ‘culture
of patient safety‘ with full buy-in by all members of the team? How can patients be
sure that they will not be exposed to the learning curve of a new procedure or a young
surgeon in training?
Ironically, the high standard of regulatory compliance-mandated patient safety protocols
in the United States emanates from decades of work by lawyers and patient advocacy
groups, not from physician-driven initiative. It is time to end this historic negligence.
It is time for surgeons to direct and own patient safety as a ‘surgical responsibility’.
More than 200 million surgeries are performed worldwide each year [6]. Any patient
admitted to a hospital to undergo a surgical procedure should rightfully expect to
be better off after the intervention than before. However, recent reports reveal that
adverse event rates for surgical conditions remain unacceptably high, despite multiple
nationwide and global patient safety initiatives over the past decade [7]. These include
the ’100,000 Lives Campaign’ (2005/2006) and subsequent ‘5 Million Lives Campaign’
(2007/2008) by the Institute for Healthcare Improvement (IHI), the ‘Surgical Care
Improvement Project’ (2006) and ‘Universal Protocol’ (2009) by the Joint Commission,
and the WHO ‘Safe Surgery Saves Lives’ campaign accompanied by the global implementation
of the WHO surgical safety checklist (2009) [8-13].
Many of the current limitations to the creation of a globally recognized and consistently
practiced ‘culture of patient safety’ stem from the lack of surgeon-driven leadership.
Transparent leadership and credible role modelling are the prerequisites to ensure
unwavering ‘buy-in’ by all members of the health care team for adoption of safety
practices in the daily routine, including strict adherence to patient safety checklists
and safety core measures [14]. We are furthermore lacking a uniform system for reporting
and analysis of surgical complications, which could be modelled on the Problem Reporting
and Corrective Action (PRACA) quality assurance database by the National Aeronautics
and Space Administration (NASA) [15]. Errors in the surgical care of our patients
frequently lead to unintentional harm on first occurrence in absence of a ‘fail-safe’
backup option. We should learn from other high-risk domains, including nuclear technology,
professional aviation, naval submarine technology, and aerospace engineering that
have historically embraced a culture of safety as a basic tenet for the success in
their respective missions. In engineering, ‘redundancy’ implies the ‘fail-safe’ duplicate
or triplicate availability of critical components or system functions. For example,
NASA endorses the fundamental principle of being ‘double-fail-safe’ in all aspects
of their enterprise [15].
Patient safety in surgery should model on the 5 core principles from NASA’s proven
safety culture paradigm:
1. Reporting culture – Reporting concerns without fear of reprisal.
2. Learning culture – Learning from successes and failures.
3. Flexible culture – Changing and adapting to meet new demands.
4. Engaged culture – Everyone is doing their part.
5. Just culture – Treating each other fairly.
The extrapolation of these proven safety pillars from aerospace engineering to patient
safety in surgery is challenged by multiple barriers imposed by our current health
care system. Based on the premise that “Good judgment comes from experience which
comes from poor judgment” (Figure 1), NASA’s safety culture originated from lessons
learned through system failure analysis after dramatic fatal accidents, including
the Apollo 1 cabin fire in 1967, and the space shuttle disasters in 1986 and 2003.
In surgery, we are still falling short of implementing a formal ‘culture of reporting
and learning’.
Figure 1
Paradigm of the learning curve in surgery and other high-risk domains.
In the absence of the long overdue legislative tort reform needed to avoid penalties
for publicly reporting medical errors, surgeons remain understandably reluctant to
disclose surgical complications in an open and transparent forum [16,17]. The deterrent
of potential punitive measures could be mitigated by adopting a model from professional
aviation safety, such as the amnesty program used by the U.S. Federal Aviation Administration
(FAA). The FAA program is designed to incentivize pilots and air traffic controllers
to report poor personal conduct, including sleeping on duty or falsifying records.
The FAA claims that since the implementation of the amnesty program “No other safety
program has identified and fixed more local and systemic problems in any other high-risk
domain”[18].
In medicine, the absence of formal amnesty programs combined with the daunting threat
of legal repercussions for admitting and reporting errors and complications, appears
to breed a converse ‘culture of silence and intolerance’. The current pressure of
the medicolegal industry furthermore promotes a ‘culture of defensive medicine’ by
setting a standard expectation for diagnostic precision that borders on fantasy. The
unintentional fallout from practicing defensive medicine is a drastic exacerbation
of health care costs, with little or no benefit to the patient, in conjunction with
an increased risk for ‘collateral damage’ by the overuse of diagnostic testing [19,20].
For example, the exponentially increased use of medical imaging by computed tomography
scans in recent years has been associated with an incremental long-term risk of radiation-induced
cancer [21-23]. Further unresolved problems include the wide variation of surgical
indications worldwide, the inequity of access to surgery for disparities, and a questionable
long-term sustainability of surgical quality at the current rate of progress associated
with increasing costs for modern and innovative procedures [6,14].
An additional serious challenge to patient safety in surgery consists of the questionable
quality of training for the next generation of surgeons. The desperate need for more
primary care doctors in the coming years and decades prompted selected medical schools
in the United States to shorten their teaching curriculum to just 3 years by shaving
off one full year of training [24]. This ’fast-track MD’ program is certainly appealing
by saving tuition costs and addressing the predicted shortage of primary care physicians.
However, cutting the training curriculum of new physicians appears rather counter-intuitive
from a patient safety and quality perspective. Additionally, the surgical experience
of residents in training has been drastically impaired by the implementation of resident
work hour restrictions [25-28]. Ironically, work hour restrictions were implemented
as a patient safety measure to mitigate the risk of surgical complications originating
from overworked and fatigued residents. Contrary to the original intent, a decade
of international experience with resident work hour restrictions revealed that patients
are not safer, but rather more susceptible to harm originating from handovers of care,
equivocal physician accountability, and breakdowns in communication within the team
[28-34]. In addition, multiple studies on millions of hospital admissions in different
countries reported a lack of an effect of resident work hour restrictions on patient
morbidity and mortality, bringing into question the primary intent of the program
in the first place.
Surgeons are under an increasing amount of pressure and expectation to perform at
the highest level. They must deliver absolute diagnostic accuracy and infallible surgical
quality under the conflicting paradigm of patient safety and maximal cost efficiency.
In addition, surgeons are expected to have the highest standards of ethical values
and professionalism, to act as respected role models, dedicated teachers, academic
researchers, successful administrators and entrepreneurs. While no medical student
would ever learn about managing a business during medical school, surgeons are increasingly
requested to provide cost-efficient care under an increasingly competitive ‘health
care market’. These expectations come close to the task of squaring the circle even
for experienced surgeons, but are virtually unattainable for physicians in training
who are denied adequate access to surgical ‘hands-on’ training in the current age
of work hour restrictions and ‘fast-track’ teaching curricula. We are worried that
the next generation of surgeons may not have an adequate opportunity of learning ’how
to cut’ and may have to postpone the learning curve from training (Figure 1) to an
unsupervised surgical practice in later years. This is certainly not in the patients’
best interest.
An intuitive solution, in light of the demonstrated absence of a positive effect of
resident work hour restrictions on patient safety and outcomes, is for accreditation
councils of residency programs to reconsider the value and far-reaching consequences
of work hour restrictions, and to potentially drop this inefficient program. In addition,
it is our obligation as senior surgeons to act as role models to our trainees with
regard to professionalism and individual physician accountability, and to prove these
values in daily interactions with our team [35]. As we observed the historic paradigm
shift from a ‘culture of blame and shame’ to a ‘culture of systems safety’, we have
now reached a tipping point in which the expectation of systems are exhausted, and
a physician-driven approach is needed to build and sustain a ‘culture of individual
accountability’. A classic example is hand hygiene as a simple core measure with immense
impact on patient safety with regard to decreasing the incidence of hospital-acquired
infections. International estimates show that overall compliance with hand hygiene
among health care personnel is as low as 5% to 30% [36-38]. A ‘perfect’ system can
provide staff training programs and logistic support, including door signs, checklists,
and hand sanitizer dispensers in- and outside of patient rooms. However, in absence
of individual accountability and physician-driven leadership, the expected goal of
100% hand hygiene compliance remains utopic. How is it possible that low-wage workers
in the meat packing industry are able to sustain 100% compliance with hand hygiene
protocols, but physicians can’t? Intriguing insights from our own institution reveal
that hand hygiene compliance rates drop from more than 90% when officially observed
and monitored, to less than 40% when we feel unobserved. This phenomenon likely relates
to the ‘Hawthorne effect’ by which a subject’s behavior changes as a result of being
observed, and reflects poorly on the physicians’ accountability for ‘doing the right
thing’ for our patients at all times.
On a positive side, the historic dogma that physicians are infallible has worn off
and has been replaced by a modern concept of patient-centered care, with patient safety
as its core tenet. The concept of involving patients and families in a ‘shared decision-making’
approach for surgical care has globally evolved in recent years as a cornerstone of
patient-centered care (“Nothing about me without me!”) [39]. Despite all limitations
and barriers outlined in this editorial which continue to impede the implementation
of a sustainable and global ‘culture of patient safety’, we are extremely positive
that the future for our patients is bright! We see the bright future every day in
the eyes of our trainees, medical students and residents, in their unlimited enthusiasm
and proactive engagement in all aspects related to patient safety, quality assurance
and quality improvement. The only benchmark for our success as mentors is to produce
trainees who will be better surgeons and stronger patient safety advocates than we
could have ever been in our own life time [40,41].
The legendary Flight Director of the lunar Apollo missions, Gene Kranz, stated in
the wake of the Apollo 1 disaster in 1967 [15]:
“From this day forward, Flight Control will be known by two words: ‘Tough and competent’.
Tough means that we are forever accountable for what we do or what we fail to do.
We will never again compromise our responsibilities. Competent means we will never
take anything for granted. We will never be found short in our knowledge and in our
skills.”
It is time for surgeons to become ‘tough and competent’ in patient safety!
Competing interests
All authors are members of the Patient Safety in Surgery editorial board. The authors
declare no financial conflict of interest related to this manuscript.
Authors’ contribution
PFS designed and drafted the first version of this editorial. All authors contributed
equally to revisions of the manuscript. All authors read and approved the final version
of the editorial prior to submission.