From the Wards
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We Lost It: A Story of Surgical Error

I will admit to being an “OR avoider” — albeit, one who is certainly in awe of the stylized pageantry of sterile armor adornment. In the operating room, safe spaces are demarcated by mere inches. Rest your hand beyond the thresholds monitored by the scrub techs and you are deemed a threat to a clean procedure. Gesturing in ways that are otherwise socially advantageous gives new territory to harmful bacteria that threaten favorable outcomes.

As third-year medical students, we are taught patient safety in the instruction we receive on behaviors that adhere to evidence-based guidelines for minimizing surgical complications. This education undeniably evolves with our understanding of the science and systems that underline medical practice. For me, a specific OR experience remarkably transformed and accelerated my education in patient safety. Witnessing and participating in the unfolding of a medical error made me rethink the resources necessary and available for safe medical decision-making.

Our case was a laparoscopic inguinal hernia repair. Nothing in the team’s preoperative routine diverged from the customs designed to optimize surgical results. We reviewed the patient’s chart to confirm that the proper procedure with the right location would be performed for the correct person. Surgical sites were marked. Consent was reiterated and lingering questions were answered. Once in the OR, a time-out ensued. Sterile drapes were positioned. We began, seemingly without event.

Shallow anatomical planes defined the workspace. To reach from abdomen to groin, small incisions were made, into which even smaller trocars were placed. Technical success required delicate coordination between surgeon, equipment and fascia. The torn tissue arose in view prompting the scrub tech to offer a needle for the repair. A few millimeters of steeply curved medical technology, the needle seemed an odd match for the exacting straightness of the trocar. The surgeon reflexively shared this sentiment. “This needle won’t fit.” But with a curious reversal of opinion bolstered by an unobserved expression of logic, the needle was advanced. And it complied with stiff walls of the trocar. But did it emerge unchanged? Dissatisfied with the progress after several turns of the needle, the surgeon pulled back on the anchoring suture. Only its frayed end returned. The needle was lost in the patient.

The pivot from progress to error in our case was the consequence of multiple factors. We were time pressured. Several complex cases were scheduled after our case, and regiment loomed large in the stated objectives of the team. We were performance pressured. The surgeon had only completed a few inguinal hernia repairs laparoscopically. Moreover, the relative newness of the procedure certainly extended to me as well as the assisting senior resident who was a relative novice with these procedures. We were decision pressured. We had delayed seeking assistance at key junctures. Thus, procedural unfamiliarity and uncertainty stood in the stead of seasoned guidance that might have reformed aberrant decisions.

These challenges are certainly not novel. But our preparation and impulses could most favorably be described as inadequate. Reflecting on our situation and reviewing patient safety literature, several mechanisms stand out as potential safety measures. For one, tethering individual accountability to a bias for inquiry transforms any moment of participation into a platform for turnaround. Practically, this means that we promptly ask questions and seek expertise as we become more uncertain. Culturally, this demands that we work to dismantle norms that concentrate authority in any one person or in any one paradigm. Secondly, investing in ritualized protocols and appropriate interruptions that include equipment checklists and intraoperative time-outs are powerful add-ons to reduce risk. These practices help eliminate unneeded patient risks and work to protect the patient. Lastly, empowering healthcare teams with viable resources to manage workflow represents a formidable stake in protecting patients. Such resources can be articulated from multiple perspectives. That is, institutions can establish workload management policies, practitioners can advocate for optimal staffing, and even national authorities can weigh in with analysis of protocols that address safety in workflow.

Ultimately, a senior surgeon was called for guidance. Multiple rounds of imaging were completed. The consensus of data gathered and expertise elicited settled on making an open abdominal incision. Subsequently, the needle was recovered. The attending surgeon and senior partner openly discussed their intention to fully disclose the error to the patient and patient’s family. Unfortunately, I was not able to see the patient in recovery and gauge his reaction to the phalanx of staples meandering on his abdomen. Nor was I privy to the disclosure between surgeon and patient where the events of the surgery were recounted. My hope is that all was ultimately well.

The lessons from this case have motivated me to strike new commitments to patient safety.  I was encouraged by the culture of safety and disclosure that flanked our case. This culture has been nurtured through years of patient safety scholarship and grooming leaders who are open and willing to learn from their organization’s mistakes. Yet, there were deficiencies in our approach that reveal avenues for sustained improvement.  As I contemplate integrating technology with the norms of medical practice, I am thus driven to advocate for a framework where questions are viewed as assets, pooled expertise is the default for tackling uncertainty and professional accountability includes the authority to command resources to optimize safety.

Dacia Russell Dacia Russell (2 Posts)

Contributing Writer Emeritus

Ohio State University College of Medicine

Dacia Russell is a Class of 2015 medical student at The Ohio State University College of Medicine. She comes to medical school with a broad-based background in legal policy and community development. Dacia graduated magna cum laude from Harvard College with a degree in chemistry and a French language citation.

Since college, she has worked in economic development, health policy and law. Dacia earned a law degree at Stanford Law School and her legal training has included an externship at the United States Department of State in the Law Enforcement and Intelligence Division of the Office of the Legal Adviser. She is currently a member of the bar in New York.

Dacia intends to use her advocacy training to advance public policy aimed at improving patient safety and health care delivery. Dacia plans to pursue a career in emergency medicine and health administration.