Chapter 5. Surgical Errors

More than 20 million people undergo surgery every year in the United States alone. In the past, surgery could be extremely dangerous, in part because of the risks of the surgery itself (bleeding, infection), and in part because of the high risks of anesthesia. Because of major safety improvements in both of these areas, surgeries today are extremely safe, and anesthesia-related deaths are rare.1 Advances in surgery, anesthesia, and postoperative care have led to major declines in mortality in disorders generally treated by surgery, such as diseases of the gallbladder and appendix.2

Nevertheless, a number of troubling surgical safety issues persist. This chapter will deal with some of the more problematic issues directly related to surgery: anesthesia-related safety complications, wrong-site and wrong-patient surgery, retained foreign bodies, and surgical fires. I will end the chapter with a brief discussion of nonsurgical procedural safety.

Of course, surgery is not immune to medication errors (Chapter 4), diagnostic errors (Chapter 6), teamwork and communication errors (Chapter 9), and nosocomial infections, including surgical site infections (Chapter 10). These issues will be covered in their respective chapters, although some elements that are more specific to surgery—such as the use of the surgical checklist—will be touched on here. Early enthusiasm for the use of perioperative beta-blockers has waned after several studies in the past decade found surprisingly high rates of harm.3,4 Interested readers are referred to the latest American College of Cardiology/American Heart Association guidelines.5 For our purposes, suffice it to say that the general principles surrounding treating targeted patients with proper medications are likely to comport with similar discussions elsewhere in the book (e.g., venous thromboembolism prophylaxis, Chapter 11).

As with medication errors, in which problems from the intervention are grouped under a broad term (“adverse drug events”) that includes both errors and side effects (Chapter 4), some surgical complications occur despite impeccable care, while others are caused by errors. Surgeries account for a relatively high percentage of both adverse events and preventable adverse events. For example, one of the major chart review studies of adverse events (the Utah–Colorado study) found that 45% of all adverse events were in surgical patients; of these, 17% resulted from negligence and 17% led to permanent disability. Looked at another way, 3% of patients who underwent an operation suffered an adverse event, and half of these were preventable.6

The field of surgery has always taken safety extremely seriously. The first efforts to measure complications of care and approach them scientifically were developed by Boston surgeon Ernest Codman in the early twentieth century. Codman's “End-Result Hospital”—following every patient for evidence of errors in treatment and disseminating the results of this inquiry—was both revolutionary and highly controversial7–9 (Appendix III). Nevertheless, the American College of Surgeons soon began inspecting hospitals (in 1918), an effort that served as the forerunner of the Joint Commission (Chapter 20). More recently, the person arguably most responsible for putting safety on the radar screen of modern medicine was another surgeon, Dr. Lucian Leape.10,11 And the field of surgery has pioneered the use of comparative data (most prominently in the form of the National Surgical Quality Improvement Program12) and regional collaboratives (such as in the Northern New England Cardiovascular Disease Study Group13) to promote performance improvement.

Despite these remarkable contributions, surgery, like the rest of medicine, has traditionally approached safety as a matter of individual excellence: a complication was deemed to represent a failing by the surgeon. Our new focus on systems improvement is allowing surgery to make major advances in safety.

Beginning with a 1979 study by Luft et al. that demonstrated a relationship between higher volumes and better outcomes for certain surgeries, a substantial literature has generally supported the commonsensical notion that “practice makes perfect” when it comes to procedures.14 The precise mechanism of this relationship has not been elucidated, but it seems to hold for both the volume of individual operators (e.g., the surgeon, the interventional cardiologist) and the institution (e.g., the hospital or surgicenter).15

Although much of the volume–outcome relationship probably owes to the fact that well-functioning teams take time to gel—learning to anticipate each others' reactions and preferences—there also seems to be a learning curve for procedural competence. One of the best-studied examples is that of laparoscopic cholecystectomy, a technique that essentially replaced the more dangerous and costly open cholecystectomy in the early 1990s. As “lap choley” emerged as the preferred procedure for gallbladder removal, tens of thousands of practicing surgeons needed to learn the procedure well after the completion of their formal training, providing an organic test of the volume–outcome curve.

The findings were sobering. One early study of lap choleys showed that injuries to the common bile duct dropped almost 20-fold once surgeons had at least a dozen cases under their belts.16 After that, the learning curve flattened, but not by much: the rate of common bile duct injury on the 30th case was still 10 times higher than the rate after 50 cases.

One can assume that most graduates of today's surgical residencies are well trained in the techniques of laparoscopic surgery. But in the early days of a new procedure, patients have no such reassurance. A 1991 survey found that only 45% of 165 practicing surgeons who had participated in a 2-day practical course on laparoscopic cholecystectomy felt the workshop had left them adequately prepared to start performing the procedure. Yet three-quarters of these surgeons reported that they implemented the new procedure immediately after returning to their practices.17

Obviously, part of the solution to the volume–outcome and learning curve conundrums will lie in new training models, including the use of realistic simulation (Chapter 17). In fact, one study found that surgical residents who underwent simulation training until they reached a predefined level of proficiency were three times less likely to commit technical errors during laparoscopic cholecystectomy than those who received traditional training.18 In addition, some surgical and procedural specialties are now requiring minimum volumes for privileging and board certification, and a major coalition of payers (the Leapfrog Group) promotes high-volume centers as one of its safety standards under the banner of “evidence-based hospital referral” (Table 5-1). Certain states or insurers are insisting on minimum volumes or channeling patients to higher volume providers; institutions that achieve good outcomes and have high volumes are sometimes dubbed “Centers of Excellence.”

Although such policies appear attractive at first, they are not without their own risks. First, patients may not be anxious to travel long distances to receive care from high-volume providers or institutions. Second, volumes that are too high may actually compromise quality by overtaxing institutions or physicians. Finally, many of the procedures being discussed, such as cardiac or transplant surgery, are relatively lucrative. Losing them could threaten the economic viability of low-volume institutions, which often cross-subsidize nonprofitable services (care of the uninsured, trauma care) with profits from the well-reimbursed surgeries.

This is not to say that channeling patients to high-volume (or better yet, demonstrably safer or higher quality19) doctors and practices is a mistake, but rather that it is a complex maneuver that requires thoughtful consideration of both expected and unforeseen consequences.

Although it is often stated that the modern patient safety movement began in late 1999 with the publication of To Err is Human,20 the field of anesthesia is a noteworthy exception. Anesthesia began focusing on safety a generation earlier, and its success story holds lessons for the rest of the patient safety field.

In 1972, a young engineer named Jeff Cooper began work at the Anesthesia Bioengineering Unit at Massachusetts General Hospital (MGH). Like Codman 60 years earlier, what he saw at MGH bothered him: mistakes were common, cover-ups were the norm, and systems to prevent errors were glaringly absent. Even worse, many procedures and environments appeared to be all but designed to promote errors. For example, he noticed that turning the dial clockwise increased the dose of anesthetic in some anesthesia machines, and decreased it in others. After delivering a lecture entitled “The Anesthesia Machine: An Accident Waiting to Happen,” Cooper and his colleagues began looking at procedures and equipment through a human factors lens (Chapter 7), using the technique of “critical incident analysis” to explore all causative factors for mistakes.21–23

Around the same time, anesthesiology was in the midst of a malpractice crisis characterized by terrific acrimony and skyrocketing premiums. Other researchers, recognizing the possibility that there might be error patterns, began a careful review of settled malpractice cases for themes and lessons (“closed-case analysis”).24 And they found such patterns, in the form of poor machine design, lack of standardization, lax policies and procedures, poor education, and more.

The research and insights from Cooper's work and the closed-case analyses were important, but they needed to be brought into the mainstream, particularly among physicians. Luckily, as so often happens, the right person emerged at the right time. Ellison “Jeep” Pierce assumed the presidency of the American Society of Anesthesiologists in 1983. Energized by the experience of a friend's daughter who died under anesthesia during a routine dental procedure, Pierce conceived of a foundation to help support work to make care safer—in fact, he probably coined the term “patient safety” in founding the Anesthesia Patient Safety Foundation (APSF).25 APSF, working closely with other professional, healthcare, and industry groups, helped push the field forward, beginning by convincing caregivers that there was a real problem and that it was soluble with the right approach.26,27

What lessons from anesthesia are relevant to our broader efforts to improve overall patient safety?1,28,29 First, safety requires strong leadership, with a commitment to openness and a willingness to embrace change. Second, learning from past mistakes is an essential part of patient safety. In the case of anesthesia, the closed-case reviews led to key insights. Third, although technology is not the complete answer to safety, it must be a part of the answer. In anesthesia, the thoughtful application of oximetry, capnography, and automated blood pressure monitoring has been vital. Fourth, where applicable, the use of human factors engineering and forcing functions can markedly enhance safety (Chapter 7). For example, changing the anesthesia tubing so that the incorrect gasses could not be hooked up was crucial; this was a far more effective maneuver than trying to educate or remind anesthesiologists about the possibility of mix-ups. Finally, anesthesia was in the throes of a malpractice crisis and had a number of highly visible errors reported in the media. Sparks like these are often necessary to disrupt the inertia and denial that can undermine so many safety efforts. In the 1980s, anesthesiologists paid exorbitant rates for malpractice insurance—among the highest in the medical profession. Now that errors causing patient harm are so unusual, today's rates fall in the midrange of all specialties, a good example of the “business case for safety.”

In 1995, Willie King, a 51-year-old diabetic man with severe peripheral vascular disease, checked into a hospital in Tampa, Florida, for amputation of a gangrenous right leg. The admitting clerk mistakenly entered into the computer system that Mr. King was there for a left below-the-knee amputation. An alert floor nurse caught the error after seeing a printout of the day's operating room (OR) schedule; she called the OR to correct the mistake. A scrub nurse made a handwritten correction to the printed schedule, but the computer's schedule was not changed. Since this computer schedule was the source of subsequent printed copies, copies of the incorrect schedule were distributed around the OR and hospital. King's surgeon entered the OR, read the wrong procedure off one of the printed schedules, prepped the wrong leg, and then began to amputate it. The error was discovered partway through the surgery, too late to save the left leg. Of course, the gangrenous right leg still needed to be removed, and a few weeks later it was, leaving King a double amputee.

Events like these are so egregious that they have been dubbed “Never Events”—meaning that they should never occur under any circumstances (Appendix VI). And who could possibly disagree? While one major study estimated the incidence of wrong-site or wrong-patient surgery to be approximately 1 in every 100,000 operations,30 other studies—particularly those that also considered outpatient surgery and nonsurgical procedures—have given higher estimates.31,32 And in one survey of approximately 1000 hand surgeons, 20% admitted to having operated on the wrong site at least once in their career, and an additional 16% had prepared to operate on the wrong site but caught themselves just in time.33

When one hears of wrong-site or wrong-patient procedures, it is difficult to resist the instinct to assign blame, usually to the operating surgeon. Yet we know there must be something more at play than simply a careless surgeon or nurse. The answer, as usual, is Swiss cheese (Chapter 2) and bad systems. Appreciating this makes clear the need for a multidimensional approach aimed at preventing the inevitable human slips from causing terrible harm.

The Joint Commission has promoted the use of the Universal Protocol to prevent wrong-site and wrong-patient surgery and procedures (Table 5-2). In essence, the Protocol acknowledges that single solutions to this problem are destined to fail, and that robust fixes depend on multiple overlapping layers of protection. Several elements of the Universal Protocol merit further comment.

At first glance, sign-your-site—the surgeon marks the surgical site in indelible ink after verifying the correct site—would appear to be a particularly strong solution. But the early history of sign-your-site demonstrates that even reasonable safety solutions are destined to fail without strong standard policies and enforcement protocols. In the mid-1990s, before the Joint Commission or surgical professional societies entered the fray, a number of well-meaning orthopedic surgeons began to use markings to help ensure that they operated on the correct surgical site. Unfortunately, without a standardized approach, the result would have been nearly comical if it wasn't so scary: some surgeons placed an “X” on the surgical site (as in “X marks the spot”), while others placed an “X” on the opposite limb (as in “don't cut here”). Although there were no documented cases of wrong-site surgery resulting from this anarchy, the implementation of standard rules was crucial (under the Universal Protocol, the surgical site is the only one to be marked). Even today, the effectiveness of site marking depends on its correct implementation (Figure 5-1).34 We have also learned that the same strategies that help prevent laterality errors (right vs. left arm) may not work for other types of wrong-site surgery, such as incorrect spinal level errors.35

Another key element in the Universal Protocol is the time out, during which the entire surgical team is supposed to huddle and briefly discuss and agree upon the patient's name and intended procedure. This too seems like a robust safety solution, a fail-safe step sure to catch any errors that eluded prior protections. Yet we have come to recognize how dependent this step is on having a culture of safety (Chapters 9 and 15), one in which people low in the hierarchy are comfortable raising their concerns “up the authority gradient.” Without a safe culture and good communication, interventions such as time outs can be robotic and perfunctory, providing the illusion, rather than the reality, of safety.31

While the components of the Universal Protocol made sense and likely led to some improvements in surgical safety, this is yet another example (like medication reconciliation, discussed in Chapter 4) in which a more holistic approach, one that respected the challenges of achieving meaningful changes within complex adaptive systems (Chapter 2), was needed.34 The past several years have seen a number of successful experiments that embedded the core processes (such as sign-your-site and preoperative time outs and briefings36) within a broader set of activities designed to create a culture of safety, encourage communication, increase situational awareness, and focus all of the members of the surgical team on the task at hand.37,38

The first such effort was an eight-hospital international study that combined the use of the World Health Organization's Surgical Safety Checklist (Figure 5-2) with a variety of other activities designed to improve teamwork and communication.39 While its results—a nearly 50% decrease in deaths and complications, at both rich and poor hospitals—were impressive, the findings have been questioned in light of the study's before-and-after design, the absence of controls for confounding variables, and the fact that the outcomes did not correlate with the degree of compliance with the intervention.40

Reassuringly, an even more comprehensive surgical safety intervention (this one involved 11 distinct checklists applied by caregivers along the surgical continuum) was implemented at six teaching hospitals in the Netherlands.41 Patients at participating hospitals had 30% fewer complications and a nearly 50% lower mortality rate than those at control institutions. As in the seminal study in Michigan ICUs (Chapter 10)—in which a checklist-based intervention resulted in major decreases in central line–associated bloodstream infections, leading many people to focus on the checklist as a magic bullet42,43—both the WHO and Netherlands study authors emphasized the importance of culture change and teamwork as key success factors.39,41 In fact, the WHO investigators subsequently demonstrated that improvements in safety culture correlated with the improved surgical outcomes.44 Moreover, a study of the implementation of teamwork training (along with checklists) in 74 Veterans Affairs hospitals found a striking improvement in surgical mortality, along with evidence of a dose–response curve.45

It is clear that checklists are part of the answer, but only part. Because issues related to checklists, teamwork, and culture have become so central to the entire field of patient safety, I will discuss them more fully in Chapter 15.

In October 2002, a Canadian woman repeatedly tripped the alarm on a metal detector as she attempted to board a flight in Regina, Saskatchewan. On a closer search, the detector wand continued to bleep as it was passed over her abdomen. Since security personnel were unable to identify anything metallic on her person, they let her board her flight to Calgary. The woman wondered whether the episode was related to the recurrent stomach pain she'd been experiencing since her abdominal surgery four months earlier. After her trip, she saw her doctor, who ordered an abdominal x-ray. Shockingly, it showed the outline of a metal retractor, a tool used by the surgical team months earlier. The surgeons had inadvertently left the object behind when they closed up, which was no small feat—the retractor was a foot long and 2 inches wide, practically the size of a crowbar.

The term “retained sponge” (also called “gossypibomas,” from the Latin “gossypium” [cotton] and “boma” [place of concealment]46) is often used as a catchall phrase for all manner of surgical paraphernalia left behind after surgery. A review by Gawande et al. of 54 patients with retained foreign bodies over a 16-year period found that roughly two-thirds were actual sponges—square or rectangular bits of absorbent gauze designed to soak up blood in the operative field—while the remaining one-third were surgical instruments.47 This frequency corresponds to an overall “retained sponge” rate of about 1 per 10,000 surgeries, which works out to at least one case each year for a typical large hospital in the United States. Because the study drew its sample from malpractice cases, the problem is undoubtedly more common than this published estimate. In fact, a more recent study found a retained foreign object rate of 1 per 5500 operations.48 Determining actual incidence figures is made more challenging by the fact that the average retained surgical sponge is discovered seven years after the surgery.49

Unlike many other safety problems, the retained sponge/instrument problem would seem to be preventable by the thoughtful implementation of systematic, mechanical solutions. In the 1940s, manufacturers produced sponges with loops that were attached to a 2-in metal ring. The ring then hung outside the operative field while the sponges were placed inside the field. When the operation was over, the nurse simply harvested the sponges by gathering the rings—the way a trail of fishing hooks is pulled out of the water by reeling in the line. Clever as this sounds, surgeons found the ring system unwieldy, and many simply cut the rings off: a classic example of a routine rule violation (Chapter 15).50 By the 1960s, manufacturers tried another approach, producing surgical sponges with an embedded radiopaque thread (Figure 5-3A) meant to show up on x-rays (Figure 5-3B). But obtaining a postoperative x-ray on every patient is impractical, so the x-ray solution usually comes into play many months later, when a patient has persistent postoperative pain and the doctors are trying to figure out why.

To laypeople, leaving a sponge or tool behind may seem like a particularly boneheaded error—until you remember that complex or emergency surgeries often require dozens, even hundreds, of sponges (along with scores of other instruments and needles), often placed under considerable time pressure. This is one reason surgical teams have long used “sponge, sharp, and instrument counts.” The standard protocol requires four separate counts: when the instruments are set up and the sponges are unpacked, when the surgery begins and the items are called for and used, at the time of closure, and during external suturing. Unfortunately, the chaotic and pressured circumstances in most busy ORs and the frequent changes in personnel,51 coupled with the reluctance of the nurses to admit (consciously or not) to the fallacy of an earlier count, create situations in which the counts fail. In the most startling finding of Gawande et al., while one-third of the retained sponge cases had not been subject to a documented count, two-thirds of the cases were.47 And in about half the cases, there were actually multiple counts documented to be in agreement. This means that every sponge and instrument was accounted for, despite the fact that one would turn up later—rather inconveniently—in a patient's abdomen.

The real lesson from all of this is that what appears to be a perfectly logical safety practice often turns out to be highly imperfect. Because sponge counts of any kind are inherently unreliable, some experts have recommended taking an x-ray of every surgical site before the field is sutured. Even if x-rays were free and patients and staff were willing to put up with the procedure, keeping anesthetized surgical patients on the table any longer than strictly necessary creates its own problems. Partly for this reason, Gawande and his colleagues recommend x-rays only in high-risk cases: those involving emergency surgery, prolonged surgery, surgery that required a real-time change in clinical strategy, and surgery on obese patients. Even this plan has gaps, because radiopaque markers are subtle and can be overlooked on x-rays.48

Ultimately, the best solution to the retained sponge problem probably lies in new technology. Some companies have developed bar-coded sponges to aid in the counting process,51 while others have embedded their sponges with radio-frequency ID tags that cause a detector wand to beep when the surgeon waves it over the field before closure.52 Still others have built automatic “sponge counters,” resembling tollbooth coin machines, which can be loaded up and checked after every surgery. Although the experience with these technologies is still limited, institutions utilizing them have reported positive results. In a decision-analytic model, both the bar-coded sponge and radio-frequency-tagged sponge systems appear to be more cost-effective than either sponge counting or programs of universal or selective postprocedure radiographs (bar coding is less expensive than radio-frequency tagging, but probably takes more nursing time to use).53 It seems likely that one or several of these technological solutions will be ready for widespread implementation soon, hopefully rendering gossypibomas a historical curiosity.

Surgical fires are unusual but frightening and potentially deadly. It has been estimated that there are between 50 and 200 such fires annually in the United States, leading to morbidity in 20% of cases (often severe, including tracheal or pulmonary burns) and one or two deaths.46,54

The genesis of surgical fires, one-third of which involve the airways, is the confluence of what has been called the fire safety triangle: an ignition source (such as electrocautery and lasers), a fuel source (e.g., gauze, drapes, even endotracheal tubes [Figure 5-4]), and oxidizers (usually oxygen but sometimes nitrous oxide). Concerns about OR fires were very high in the distant past, but interest (and risk) waned with the ending of the era of flammable anesthetics about 25 years ago. The recent uptick in concern likely relates to the more frequent use of cautery and lasers in the OR, and more aggressive use of oxygen in anesthetized patients.55

A series of prevention maneuvers has been recommended, addressing all three elements of the triangle.54 They include: ignition sources should be stored away from the patients and their tips should be visualized while hot, time should be allowed for alcohol-based prep solutions to dry prior to draping patients, oxygen concentrations should be kept to the lowest safe amount, and cautery around the airway should be used sparingly and only after the anesthesiologist is warned so that he or she can turn down the oxygen.

In case of a fire in the OR or procedural suite, all personnel should be immediately notified. For fires involving the airway, the flow of gas should be turned off and the airway cooled with normal saline. For fires in other locations, smothering with water, saline, or by physical means is advised; use of a carbon dioxide fire extinguisher should be reserved for persistent flames.

While most of the attention regarding procedural safety has focused on surgical operations, there is growing recognition that nonsurgical procedures carry risks as well. As we turn our attention to bedside procedures, it is worth appreciating some differences between the two domains. One big one: the OR is (on a good day) an organized system of care, where policies and procedures can be enacted and measured, and individual participants can be given responsibility for compliance (i.e., “The circulating nurse will not allow the procedure to begin until the time out has been completed”). On the other hand, some procedures (such as thoracentesis and central line placement) may involve only a single physician and his or her patient, offering fewer opportunities for independent double checks.

Complication rates for certain bedside procedures are surprisingly high. For example, 6% of thoracenteses result in a pneumothorax, one-third of which require chest tube placement.56 Central venous catheter placement can be very risky, with complication rates (arterial laceration, pneumothorax, thrombosis, and infection) exceeding 15%.57 Paracentesis, lumbar puncture, and arthrocentesis are somewhat safer, but all have significant risks.58,59

Strategies to decrease the risks of procedures fall into several categories: education and skill building, policies and practices to decrease overall process risks such as wrong-patient and wrong-site procedures, adjunctive technologies, and organizational changes.

There is abundant evidence that our traditional academic strategy of “see one, do one, teach one” is both ineffective and unethical (Chapter 17). As one window into this, studies have shown that many residents remain uncomfortable with certain procedures even after being charged with supervising them for their junior colleagues.60 Most of the advances in the area of education and skill building have come through the development of formal curricula and competency-based assessment strategies—including forbidding learners from performing procedures independently until they have been deemed competent.61,62 (The use of simulation to enhance both teaching and assessment of procedures is further discussed in Chapter 17.) There are now a number of Web-based aids (the videos produced by the New England Journal of Medicine are the best I've seen63) that demonstrate correct technique and pitfalls far better than a static textbook chapter or monograph ever could.

Bedside procedures are at risk for the same kinds of wrong-site and wrong-patient errors that I discussed earlier. In fact, a study of 132 self-reported wrong-site or wrong-patient events found that similar numbers came from nonoperative procedures as formal surgeries.64 The Joint Commission requires the bedside proceduralist to perform the same Universal Protocol for bedside procedures as is required for major surgical operations.65,66 While it is permissible for an individual proceduralist to go through the Protocol alone, bringing another person in the room for an independent check is a sound practice. Barsuk et al. reengineered the procedure process—including adding requirements for procedural kits (which included relevant checklists) to be signed out by nurses from locked storage cabinets (a forcing function, Chapter 7) and that nurses be present at all procedures—and found that compliance with the Universal Protocol skyrocketed, from 16% to 94%.67

Adjunctive technologies can be quite helpful. The most important is bedside ultrasound, whose use drastically lowers the rates of pneumothorax after thoracentesis and both pneumothorax and subsequent infection (the latter improvement likely owing to fewer sticks) after central line placement.56,57 Learning to use bedside ultrasound correctly is not trivial, and teaching this skill should be integrated into the educational program described above.61,62 Of course, other technologies may more directly improve the safety of certain procedures. For example, the availability of peripherally inserted central catheters (PICC lines) has obviated the need for subclavian or jugular puncture in some patients who require access to the central circulation.

Finally, some hospitals have developed dedicated procedure services to improve the safety of procedures. These services are staffed by a limited number of physicians (frequently hospitalists) who receive additional training in the relevant procedures and commit to spending significant time on the service. Early data support the premise that such services enhance safety and patient satisfaction,68–70 probably via several mechanisms: narrowing the number of providers and thereby ensuring that those performing procedures are skilled and have high volumes, allowing for implementation of standard policies and protocols, and freeing clinicians from other distractions while performing procedures. In teaching hospitals, the procedure service not only ensures the safety of individual procedures but also takes on responsibility for educating trainees, in matters ranging from the angle of insertion of the needle to correct hygiene practices, and from the proper use of ultrasound to when a procedure is not indicated or too risky and needs to be referred to a more specialized provider (i.e., interventional radiologist). In my judgment, these services represent a major advance in patient safety and should be implemented widely.

• Patient safety issues in surgery include those common to other fields (e.g., medication errors, healthcare-associated infections, readmissions, communication mishaps), and also several specific to surgery (e.g., wrong-site surgery, retained sponges, OR fires).
• Evidence for a volume–outcome relationship in many surgical areas argues for new types of simulator training.
• Anesthesia embraced the importance of many patient safety principles (systems thinking, human factors engineering, learning from mistakes, standardization) earlier than any other field in medicine, and has amassed the most impressive safety record.
• A comprehensive application of the “Universal Protocol” (including “sign-your-site” and the preprocedural “time out”), coupled with teamwork training and the use of checklists, is currently the best strategy to prevent wrong-site and wrong-patient errors and has been demonstrated to improve surgical outcomes.
• Retained sponges and other surgical instruments is an uncommon safety hazard. Sponge counts and x-rays have traditionally been the main preventive strategies, but prevention will ultimately depend on more robust detection technologies.
• Surgical fires result from the interaction of the three elements of the fire safety triangle (ignition source, fuel source, and oxidizers). They can be prevented with adherence to a series of safety maneuvers addressing each element of the triangle.
• Nonsurgical procedures, such as thoracentesis and central line placement, carry significant risks. Robust competency-based training, proper adjunctive use of bedside ultrasound, implementing checklists and time outs, and a dedicated procedure service can decrease these risks significantly.