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SOME BASIC CONCEPTS AND TERMS
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More than 20 million people undergo surgery every year in the United States alone. Historically, surgery was considered extremely dangerous, in part because of the risks associated with the surgery itself (bleeding, infection), and in part because of the risks of anesthesia. Because of safety advances in both of these fields, 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 surgical mortality.2
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Nevertheless, a number of troubling surgical safety issues persist. This chapter will address 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. The chapter will conclude with a brief discussion of nonsurgical procedural safety.
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Of course, the field of 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 are 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.
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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.3 Another systematic review estimates that about 1 in 20 surgical patients experiences a preventable adverse event, most of which were related to perioperative care.4
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The field of surgery has always taken safety extremely seriously. In the early twentieth century, Boston surgeon Ernest Codman was among the first people in healthcare to measure complications of care and approach them scientifically. 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 controversial5–7 (Appendix III). Nevertheless, in 1918 the American College of Surgeons began inspecting hospitals, an effort that foreshadowed the Joint Commission (Chapter 20). Dr. Lucian Leape, a pediatric surgeon, is largely responsible for bringing the issue of patient safety to the fore of medical practice.8,9 In addition, the field of surgery has pioneered the use of comparative data (most prominently in the form of the National Surgical Quality Improvement Program...