Background

Medical errors are essentially acts of commission (doing something wrong) or omission (failing to do the right thing) that can lead to an undesirable outcome for the patient or that have the potential for such an outcome. They encompass a wide spectrum, but none is as hazardous to the patient or as detrimental to the psyche of the surgeon as a “wrong-site surgery.” Surgeries carried out on the wrong side or on the wrong person are amongst the most serious of surgical errors. These “surgical never events” have become a focus of media concern and attention, not to mention a source of negative publicity for the medical profession and surgical specialties. Neurosurgery is as vulnerable to the occurrence of these errors as any other branch of surgery, if not more.

Neurosurgery is the third most likely specialty to perform a wrong-site or wrong-level surgery, after orthopedic and general surgery. Wrong-side or wrong-patient procedures occur in roughly 1 case out of every 100,000 operations and in 2.2 cases of every 10,000 craniotomies. Surveys of neurosurgeons show that 25% of physicians have made an incision on the wrong side of the head, and 35% admitted to wrong-level lumbar surgery in their careers. In a survey of members of the American Academy of Neurological Surgeons performed by Mody et al., 50% of responding surgeons reported that they had performed at least one wrong-level surgery during their career. Of 418 wrong-level surgeries, 17% resulted in litigation or monetary settlement.

Is an Explanation Plausible?

Despite substantial efforts, including surgical checklists and other protective measures, the healthcare industry has not been able to eliminate the menace of wrong-site surgery. Most of the adverse events related to wrong-side or wrong-patient surgery appear to arise from breakdowns in communication. In an anonymous survey, neurosurgeons recognized fatigue, unusual time pressure, and emergent operations as factors contributing to wrong-site surgery.

It has to be recognized that for these fundamental errors, it is inappropriate to focus the responsibility entirely on the “end-of-the-line operator”—in this case the neurosurgeon. The neurosurgery operating room is a complex adaptive network in which a mix of professionals must cooperate while performing demanding technical tasks and using complex technologies and techniques. Hence the complex network of systemic factors that surround the neurosurgeon (in addition to the neurosurgeon) should be considered while offering a plausible explanation for wrong-site neurosurgery. The Swiss cheese model effectively elucidates how the complexity of our systems, when combined with human factors, can synergistically promote errors like wrong-site surgery ( Fig. 3.1 ). In the context of the systems approach, it has been suggested that when an error occurs, it is more useful to correct the system that failed than to assign blame to the individual who committed the last act in the chain of events leading to the error.

The Swiss cheese model of accident causation. Despite the presence of multiple layers of defenses, barriers, and safeguards, an error can still occur if the “holes” are all aligned.

Lessons From the Aviation Industry

Safety management in aviation and in the surgical suite is often comparable. This emulation is in the context of major achievements in the field of aviation: Despite the number of worldwide flight hours doubling over the past 20 years (from approximately 25 million in 1993 to 54 million in 2013), the number of fatalities has fallen from approximately 450 to 250 per year. This stands in comparison to health care, where in the United States alone there are an estimated 200,000 preventable medical deaths every year, which amounts to the equivalent of almost three fatal airline crashes per day.

The aviation industry functions as a high-reliability organization that has used a variety of practices to maintain an enviable safety record, despite the inherent risks of flying. The inherent risks associated with air transport, the team structure of its air crews, and the importance of a methodic approach in completing critical tasks make it in many ways similar to the perioperative setting. The safety record of the surgical setup as a whole has failed to emulate the strides taken by the aviation sector. Over the past few decades, there has been a gradual but steady move toward attempting to integrate aviation safety principles to improve perioperative patient safety. Crew resource management (CRM), incident reporting, checklists, and readbacks have been some of the most prominent principles that are slowly being adopted in the surgical suite with the intention of preventing the “surgical never events.”

Utilizing the long-term effectiveness of aviation strategies to improve perioperative safety is a work in progress, given some significant differences between aviation and the surgical suite. At least three safety-related cultural attributes appear to distinguish aviation from health care. Aviation has much more of a “blame-free culture” in the case of reporting and owning up to safety incidents. Secondly, there appear to be competing demands between economic factors and safety, with financial pressures and considerations constantly making news headlines. Thirdly, safety permeates all levels of aviation, whereas in health care it is still regarded as the priority of some, not the obligation of all. Empowering all participants in the surgical suite would be a significant step toward avoiding complications like wrong-site surgery.