Yeshwanth Pulijala
Sep 24 · 7 min read

I love surgery. I always have. Growing up, I always wanted to be a surgeon. I am not sure if it was the movies or the society that influenced me the most but doctors were treated special, and surgeons especially were treated like superheroes. Two years back we started Scalpel Ltd to improve patient safety in surgery. Since then our team spent every minute on building tools that reduce the chance of preventable errors in surgery. Along the way, we have learned a lot about why things go wrong in surgery, why the current solutions don’t work, and how can we fix it. This post shares some of those lessons.

Patients in their most vulnerable times come to surgeons and entrust their wellbeing. Below the surgeon’s sharp scalpel lies hopes, dreams, feelings, and families of people. When someone successfully performs a life-saving procedure with such a high stake, they are raised to superhuman status. This perceived status comes with a curse, the confirmation bias against mistakes.

A routine operation — but

It was just another busy day at the hospital for Prof James (names are changed). He already performed three minor procedures, assisted a major surgery, and was getting ready for his fourth procedure of the day. Outside the operating room, he met Kate, a 38 years young woman who was diagnosed with a large cyst in her left ovary. It was going to be a routine operation, something which Prof James had performed many times before. The scrub nurse checked her consent, anaesthetist took all the safety steps, and Prof James started the procedure.

Photo by JC Gellidon on Unsplash

One hour into the operation, he carefully removed the fat and tissue layers before making a swift cut into the right ovary. In a scooping motion, he removed the ovary out with the help of his residents. Everything went fine and, Kate was discharged the next day. Two years later, she was readmitted into ICU with severe pain. On performing an MRI, they realised a wrong-site surgery was performed previously. Instead of the affected left ovary, the patient’s right ovary was removed.

It was a catastrophic mistake! She was informed of the error. Eventually, her left ovary was also removed. Preventable adverse events in surgery are a major concern in hospitals.

Preventable patient harm is a public health issue.

Estimates indicate that in high-income countries, 1 in 10 patients is harmed while receiving hospital care (1). 50% of these incidents are preventable (2). In the US, over 440,000 people die every year from preventable medical errors, making it the third leading cause of death(3). Though these numbers are profoundly challenged(4), we are still dealing with a massive issue, which is an equivalent of four Boeing 737s crashing every day with no survivors left.

“No one should be harmed while receiving health care. And yet globally, at least 5 patients die every minute because of unsafe care”, said Dr Tedros Adhanom Ghebreyesus, WHO Director-General.

The situation is much worse in lower-middle-income countries. Annually 134 million adverse events due to unsafe care occur in hospitals in low resource settings contributing to 2.6 million deaths[1]. Approximately two-thirds of the global burden of adverse events resulting from unsafe care, including the disability-adjusted life years lost from them, occurs in low- and middle- income countries[1].

As explained by Matthew Syed in his book, Black Box Thinking, it is not just the number of deaths; the non-lethal harm caused by preventable errors is worrying. The number of patients who endure serious complications is estimated to be ten times higher than the number of patients killed by medical error.

As Joanne Disch, clinical professor at University of Minnesota School of Nursing put it: “We are not only dealing with 1,000 preventable deaths per day, but 1,000 preventable deaths and 10,000 preventable serious complications per affects all of us.”

When things go wrong in surgery, the consequences can be devastating not only for the patients but also for surgeons, making them second victims [7]. Surgeons suffer from guilt, risk aversion and anxiety about consequences. However, they are asked to get back on their horse and treat the next patient.

Every surgeon, as the saying goes, has their own graveyard they visit on occasion.

To Err is Human — especially in an overburdened system

Adverse events in surgery are of two types, complications and errors. While every surgery has inherent complications, there are many preventable errors. Preventable errors result from a combination of institutional systems factors and the actions of people within those systems.

Operating rooms are complex places where multiple procedures are performed by various staff in different hierarchical levels following numerous protocols on patients. Stressful situations, weekends vs weekdays, days before a vacation, weekend admissions, supervised and unsupervised cases show varying degrees of patient safety incidents.

Atul Gawande, the author of the Checklist Manifesto, describes the reason for errors could be ignorance or ineptitude. Ignorance is when we don’t know how to handle a complication. Ineptitude, on the other hand, is the inability to apply the existing knowledge. Marking the wrong site of surgery, or not marking it at all, administration error which brings a different patient into the Operating Room, communication error which leads to the removal of the wrong organ, counting mistake which leads to a retained swab in the patient’s body shows our ineptitude. On top of this, confirmation bias in clinicians can make this situation worse.

Confirmation bias, a subset of cognitive bias, contributes to overconfidence in personal beliefs in the face of contrary evidence. It can lead to behavioural patterns like “Yes, I know it happens, but it won’t happen to me”. “I have performed this procedure a zillion times, I can’t be wrong”. Problems with this kind of over resilience include burnout, high rates of depression, and tendencies to ignore the redundant checks that improve patient safety. As a consequence, mistakes occur.

Surgeons also live pressured lives. A study by Shanafelt et al. [5] showed just that with 40% of the surgeons reporting they experience burn out, 30% screened positive for symptoms of depression. This level of stress can affect the most experienced surgeons as well. Fahrenkopf et al. [6] showed that depressed residents made significantly more (six times more) medical errors than those who are not depressed.

Investment in patient safety is an urgent need

Unintended patient harm imparts a high financial cost to hospitals, insurance bodies and the public. Repeat treatments, extended bed days, lost capacity and productivity of patients and clinicians lead to massive losses to the healthcare system. This is in addition to the loss of trust in the system.

A groundbreaking report by Slawomirski et al[8] in 2008 showed that the economic cost of medical error in the US is estimated to be almost $1Trillion. The annual cost of adverse events in England is equivalent to 2000 GPs or 3500 nurses. Preventable costs estimate 2–10% of public health spending. In OECD countries, 15% of the hospital budget is attributed to treating patient safety failures.

While operating rooms (ORs) are the primary revenue and profit contributor for most hospitals, they are also one of the largest cost centres. The value of an OR minute is often marked at $100+ for a health system. Each OR minute requires valuable team member time from nursing, anaesthesia, and surgeons, as well as capacity utilisation of limited OR suites. Mistakes make the cost of an operation three times more expensive. Investments in reducing patient harm can lead to significant financial savings, and more importantly, better patient outcomes.

The Lancet report on Global Surgery showed that 5 Billion people in the world do not have access to safe and affordable surgical care[9]. We need to perform 143 million additional surgical procedures to address the global need, especially in lower-and-middle-income countries. If 50% of these operations are bound to be unsafe, we are at a major crossroad where we need to invest in innovative patient safety technologies increasingly.

Making Surgery Safer at Scalpel

With a mission to eliminate preventable surgical errors, we started Scalpel. Supported by Deep Science Ventures, Innovate UK, NIHR Surgical MIC and HS., we are building AI tools that improve patient safety in operating rooms. Frontline clinical staff, policymakers, patients and investigation managers joined us in building the gold standard of surgical safety. To learn more about Scalpel’s story and why we do what we do, listen to us on The HS. Health-Tech Podcast.

We are glad that Patient safety has finally been recognised as a top global health priority by the WHO last week. We believe every day should be treated as a Patient safety day and no one should undergo unsafe surgery. We urge clinicians and decision makers from across the world to take charge and speak for patient safety and join forces with us in making surgical errors not unavoidable but unthinkable.

Yeshwanth Pulijala

Written by

Founder of Scalpel Ltd. Builds tech to make surgery safer. Ph.D. in Mixed reality applications for Surgery. Also a Dentist.

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