DE Jaroszewski,, KL Mattox,
Despite meticulous planning and optimal patient management, avoidable comp?li?ca?tions continue to occur in thoracic sur?gery. Pitfalls leading to adverse events involve areas of preoperative, intraoperative, and postoperative care. Instituting a system that avoids these pitfalls can help practicing surgeons avert preventable errors.
DE Jaroszewski, MD, MBA Chief Resident of Cardiothoracic Surgery
Baylor College of Medicine
GL Walsh, MD
Professor of Surgery and Critical Care
MD Anderson Cancer Center
KL Mattox, MD
Professor and Vice Chairman
Michael E. DeBakey Department of Cardiothoracic Surgery
Baylor Collegeof Medicine
Chief of Staff and Surgery
Ben Taub General Hospital
MJ Wall, Jr, MD
Baylor College of Medicine
Chief of Cardiothoracic Surgery
Executive Director of Trauma and
Ben Taub General Hospital
VF Trastek, MD
Chair Board of Governors
Chief Executive Officer
Executive Administrative Offices
Mayo Clinic Scottsdale
Today's thoracic surgeon faces a challenging and continually evolving environment. Thoracic sur?gery is changing not only from outside forces but also from the inner echelons. Changes include repeated cuts in reimbursement for services while patient and societal expectations for treatment are increasing, encroachment of other specialties into areas that were previously the surgeon's domain, and a decline in applicants and interest in surgery and science-related fields.1-5 The number of qualified surgeons who complete training is shrinking, and yet over one billion pa?tients with thoracic pathology will be identified in the next century.6,7 Litigation continues to rise, and cardiothoracic surgery remains one of the most costly for malpractice insurance underwriting.8-10
Despite meticulous planning and optimal patient management, avoidable complications continue to occur in thoracic surgery. A "pitfall" is defined formally as a concealed trap or danger.11 Root-cause analysis has identified simple pitfalls that can be averted and thus, adverse events prevented. Statistics show that many surgeons fail to bypass seemingly obvious pitfalls, including those associated with preoperative, intraoperative, and postoperative care.10 Implementing a system to avoid these pitfalls can avert preventable errors for the practicing surgeon.
Pitfalls in the preoperative phase?The thoracic surgeon must first and foremost be a good clinician. Knowing when and, equally important, when not to operate is critical and can prevent career-threatening mistakes (Table 1).
Avoiding preoperative pitfalls
Make your own decision as to a patient's candidacy for surgery
l Repeat marginal tests or those with clinical
Your office staff
Do not rely on others' interpretations of studies; review all relevant test results and reports
Perform a pertinent physical examination
Order the tests needed to be sure the patient can safely undergo surgery
Review formal radiology reports for all films
Address alcohol/substance abuse issues
Evaluate family dynamics and the patient's support network
Plan ahead for any postoperative care or rehabilitation needs
Make sure there are end-of-life discussions before operating
The referring physician
?Out of necessity, treating a thoracic patient involves many different caregivers, including primary care physicians, cardiologists, and pulmonologists. Developing good relationships with referral sources is critical, but relying on someone else's analysis instead of making your own assessment is a setup for significant morbidities and mortality.
A surgeon should personally review all pertinent tests. Repeat tests if data do not support your clinical judgment, especially pulmonary function tests and out-of-date computed tomography scans, angiograms, and echocardiograms.
The office staff?Your home team in?cludes the office administration. They are your front door and window. Weekly meetings to discuss issues and preserve communication lines are critical. Patients should always feel that they have access to you through your staff's representation. This is especially important for the postoperative patient. Complications and dissatisfaction with care can lead to litigation.9,10 Often, an empathetic and re?sponsive staff can prevent this. Because of increased demands on the surgeon's time, the midlevel practitioner has be?come an integral part of the team; however, the surgeon needs to review all relevant information and documentation. Review reports and confirm what you are told. Any missing pieces of information or relying on staff members' interpretations of information could lead to serious errors.12 Additionally, the surgeon needs to perform a pertinent physical examination. A missed pathologic supraclavicular node, metastatic skin lesion, or carotid bruit could significantly alter the treatment options and course for the patient.
Preoperative evaluation?A thorough preoperative analysis must be performed to ensure a patient is medically fit for surgery. Be certain not to miss critical information in the workup that could have life-threatening consequences. Al?ways review appropriate radiographs. Radiologists occasionally may overlook subtle findings. Making a clinical decision without seeing films or taking a patient to the operating room (OR) without reviewing the official radiology re?port could lead to a serious error. If a report is incomplete when seeing the patient, use some type of system that reminds you to review that report before going into the OR. A plethora of data can help and hurt. Read every line of the report; do not miss the last sentence of a report noting a lesion in the liver "could represent" metastatic disease. Document any discrepancies found in reports. If a choice is made to clinically override something in a report, document your thinking and reasoning. Do not leave yourself open to legal or critical review by not having adequate written backup.10
Psychosocial factors?Identifying psychological factors, family dynamics, and social situations is imperative. A patient who has no family support upon discharge likely will be back in the emergency department within a week. Obtain a patient's insurance and financial op?tions for any assisted living, rehabilitation, long-term care, or other post-discharge needs that may be necessary. Alcohol and tobacco dependence should be assessed and appropriate treatment planned before the operation. The time to discover a drinking problem is not when the patient suffers delirium tremens postoperatively.
End-of-life discussions?Establish a relationship with the patient and the patient's family before the operation. The patient should designate a medical power-of-attorney and have end-of-life discussions before surgery, especially if there is any chance of significant morbidity. A patient's right to die with dignity must be honored, allowing unneeded critical care resources to be utilized better. Know what the patient would want be?fore something happens, and, ideally, get it in writing.
Avoiding pitfalls in the OR
Briefings before and after surgery
Time-out: a JCAHO mandate
Review near misses
Review special needs or problems ahead of time
Use a team approach
Add padding to all pressure points
Ensure patients are secured well
Have a system with a series of steps
Verify all equipment before using
Briefing the team on OR pitfalls?More than any other specialty, thoracic surgery is team-dependent. The surgeon must establish the role of formal leadership in the OR. Anesthesia colleagues, perfusionists, and OR nursing personnel are critical for a successful outcome. A team briefing before surgery opens communication channels and ensures everyone is on track (Table 2). Debriefings after surgery should review problems and commend successes. This model is based on the aviation industry's example of how to improve communication and teamwork, and it has been shown to de?crease errors in complex environments.13-16 Discuss anticipated issues regarding particular cases with staff and anesthesia personnel. For example, anatomic details about potential invasion of the superior vena cava would influence anesthesia's choice of central line location. If high blood loss is expected or a patient has suspected pulmonary hypertension or a left main coronary lesion, anesthesia needs to know before the case is prepared. Do not rely on others to review the patient's chart and ascertain these facts. Establish yourself in the OR as a leader who is open for communication, encourages staff to offer recommendations, and leaves room for criticism. This will foster teamwork and prevent chaos, confusion, and, most importantly, errors in the OR.12,13,16
To Err Is Human
Near misses?Time-out is a Joint Com?mission on Accreditation of Health?care Organizations (JCAHO) mandate, which requires correct identification of the patient and operative site, agreement on the procedure to be done, proper patient positioning, and establishing that necessary equipment is present.17 These important steps are the surgeon's responsibility and critical for preventing tragedy. Be sure you have the correct patient; patients can look very different with no makeup, teeth re?moved, and wig off. Confirm the radiographs are for the correct patient and verify the patient's name badge. Delegating these details to the system can be catastrophic. Stag?gered ORs, constant pages from the clinic, and other interruptions can be distracting for the surgeon. It is too late and your career destroyed once an incision is made on the wrong patient or wrong side. Do not rely on the resident or nursing staff to ensure the patient's correct side is up; personally review the radiographs. Review angiography to confirm that this is the correct patient, with the correct films and lesions. The report estimated 44,000 to 98,000 deaths occur from errors of commission in hospitals across the country.18-20 Although most of these deaths were not caused by surgical-related errors, the report highlights the need for physicians to take an active role in preventing patient errors.
Near misses?medical errors that did not cause adverse outcomes?have been incorporated into the weekly morbidity and mortality conferences in many institutions. Discussing these occurrences and ways to prevent them is critical. The patient is, after all, the last step in the administration of an error. The goal is to avert any step that ultimately leads to a patient error.21 Encourage all members of the OR team as well as nursing staff to attend. Develop reporting systems that collect and analyze information about medical errors, with emphasis on relevant information about processes of care associated with adverse events and their consequences. Systems to improve pa?tient safety should incorporate not only information about adverse events and any medical errors that cause them, but also information about near misses. The advantages of including near misses are accrual of specific errors, an increased willingness to report, increased awareness of the potential for errors, and obtaining important information about re?covery, such as how errors can be prevented from causing harm.18 Fostering open discussion without fear of criticism or blame allows staff to benefit from one another's experiences. It also provides a framework for implementing changes and developing a proactive approach to minimize preventable errors and learn how best to improve the system of delivering care.
Anesthesia?Anesthesia plays a critical role in operative treatment. De?pending on the institution, anesthesia's expertise may vary, and residents may be involved. Again, practice the team ap?proach. Review expected needs of trans?fusions, line access, endotracheal tubes, and drips. Discuss with both anesthesia and perfusion the targeted arterial pressures. If a double lumen tube is needed, confirm the placement. Assist with placement of central lines in difficult cases. Throughout the case, listen to monitors. Familiarize yourself with bells and alert sounds; know what the pulse monitor sounds like when the patient's oxygen saturation is dropping. Position the patient-monitoring screen so that it is easily seen. Remember, it is your job to get your patient through safely.
Positioning?Surgeon, nurse, and anesthesiologist should function as a unit during patient positioning. It is critical to your operation as well as for the protection of the patient. Litigation for pressure site injuries is exceedingly high.8-10,22 Verify that padding protects the lateral cutaneous, peroneal, and ulnar nerves. Check to see that grounding pads are positioned safely and not across the patient's total hip replacement scar, for example. Make sure the patient is stable, with neck aligned and not hyperextended or perched precariously on a foam donut. Patients need to be well positioned and secured so they will not twist or fall.
The operation?Everyone has a unique system and personal way of operating. Institute a system for everything?a series of steps to be followed for every operation. This facilitates efficiency and safety. You will not miss things when they are segregated into steps. Review your steps; when teaching a resident, have a discussion before, during, and after the case. Write out the major steps with residents and draw pictures. Draw on your experience to teach them how to avoid mistakes and, more importantly, how to get out of trouble. Most individuals can learn to operate, but the goal is to do it safely and reproducibly.
Your operative staff?Know your OR personnel and their levels of experience. Be cautious when a new or unfamiliar scrub is present. Review your plan with him or her and discuss the equipment that will be needed. Confirm that the stapler has the correct load and is ready for firing. Have anesthesia check the double lumen catheter, nasogastric tube, esophageal stethoscope, pulmonary artery catheters, and suction catheters before leaving the OR to ensure staples or stray stitches are not entrapped. The pleurovac system should also be checked to verify that the chambers are filled with fluid and the tubing is connected securely. You do not want this error of omission realized with the patient's code secondary to tension pneumothorax or tamponade.
Avoiding postoperative pitfalls
See patients at least every 12 hours
Make nurses a part of your team
Ensure there is adequate pain control
Ensure patients are coughing, deep breathing, and out of bed
Be honest and upfront
Never conceal an error
Never avoid a problem or problem patient
Pitfalls in postoperative care?Re?cent postoperative patients should be checked every 12 hours (Table 3). Nur?sing staff is an important part of the treatment team. Whenever possible include nursing in your rounds and planning. This ensures a better understanding of your treatment plan for the patient and minimizes calls with questions and, worse, errors related to providing im?proper medications or delayed therapies. Nursing staff will add vital information and, in your absence, remain the patient's best advocate. With restrictions on residents' hours, the roles of the nursing staff and mid-practitioner have increased substantially. Conditions can change quickly, and with proper attention subtle changes can be picked up before the patient be?comes critically ill. A therapeutic bron?choscopy, respiratory treatment, or ag?gressive diuresis may prevent a patient with increased dyspnea from progressing to respiratory distress and requiring reintubation. Adding an inotropic drip or placing a balloon pump may prevent progression of heart failure and resultant multiorgan ischemia. Mismanaged epi?durals and poor postoperative pain control should not happen.
Communication?Never overlook the importance of keeping communication lines open with your patient. Always be honest and never try to hide or conceal mistakes. If an error occurs, be upfront and ensure your patient has all the facts. Develop a close, caring relationship with each patient. Patients do not sue physicians whom they trust and believe care and have done everything possible with their best interest in mind.9,10,22
Show your presence often; this is the critical time to be present, not avoidant. High-maintenance patients may require more frequent visits. Physicians who avoid lawsuits are not necessarily the most technically gifted, diagnostically astute, or even the most respected among their peers. Instead, they are the ones who take extra time to listen and who evolve their practice to show respect for their patients' time and dignity.9,10,22
While deaths from natural causes and disease progression inevitably occur, elective major thoracic cases should be accomplished with low morbidity and mortality. Surgeons must take complications personally in order to prevent them. There is a reason for complications, and it is the surgeon's responsibility to prevent them. A useful mnemonic by Clarke is CARES18:
ommitment to safety, without compromise for efficiency;
ttention to one's own activities and those of others;
ehearsal, such as the preoperative huddle, including reserves (a backup plan) and reorganization, if needed;
ffective communication that is ac-curate, sufficient, unambiguous, and understood;
ense-making about the relationship between what is happening and what is intended.
Pitfalls are traps or openings that can lead to significant morbidities and mortality. They are complications waiting to happen and which an inexperienced surgeon may fall into. Pitfalls leading to ad?verse events involve areas of preoperative, intraoperative, and postoperative care. Armed with experience, knowledge, and the ability to recognize pitfalls, the surgeon may avoid them. Avoiding pitfalls is done by following the surgical doctrine of carefully examining one's performance and implementing changes to improve patient care.11 It is important to continue the quest to find better and safer ways to care for patients by establishing an effective error-prevention system in one's practice.
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