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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
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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.
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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).
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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
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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 ...