Mistakes in the Operating Room — Error and Responsibility
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《新英格兰医药杂志》
It happened a very long time ago, when I was a third-year medical student in my first week on the surgical service of a large university hospital. One of the interns needed time off to attend to a family emergency, and I was appointed to fill in for him.
I was never quite sure whether my temporary title of "sub-intern" was something to be proud or ashamed of. I would have been pleased as punch about it had one of my professors not recently referred to interns as "the Mortimer Snerds of the medical profession." If that characterization was even close to accurate, what was a sub-intern? In my worst moments of self-doubt, usually when I was alone and worriedly trying to solve a problem at the bedside at three in the morning, I would console myself by recalling that I had been authorized by the chief resident to introduce myself to patients as Dr. Nuland — hardly the title of a sub-anything. That kind of deception was commonplace in those days. Believing it to be justified by the necessities of our training and the importance of assuring patients of our competence, we students didn't think of such seemingly harmless fibs as the self-serving lies we later realized they were.
I had been assigned that day to assist one of the senior surgeons in the removal of a large fatty tumor that bulged outward under the skin of a patient's groin. It was hardly a major undertaking, especially since it was being performed by one of the finest — "slickest" was the accolade we used for our most dextrous teachers — operators on the hospital's staff. I'll call him Dr. Swift. Though I had never met him, Dr. Swift's reputation for speed and a certain dashing elegance preceded him. I felt confident that no problems would arise, even when he told me that he was running late for an operation at another hospital, about 10 blocks away. "Doctor, would you mind closing when I've gotten Mr. Green's lipoma out?" he asked. Too excited by the opportunity and too flattered to point out that I was a student in my sixth day at the operating table, I assented happily and self-assuredly, evidently convincing him of both my enthusiasm and my capability. Given the surgical mask on my face, he had no way of knowing that I was 22 years old.
Swift performed the operation as slickly as I had anticipated, handed the specimen to the nurse, and stepped back from the table. Hastily stripping off gown and gloves, he strode through the swinging doors of the operating room, calling out his thanks to the nurses. Over his shoulder, he gave me my orders just before disappearing up the corridor: "And by the way, doctor, just trim away that bit of extra skin to make the closure neat, OK?" He didn't wait for a reply.
I did as I was told, using curved scissors to trim the edges of the wound before beginning to stitch. In the process, however, I inadvertently cut into a large vein just under the skin, lying there as though in wait for my hapless hands. Feeling a bit panicky as the wound quickly filled with dark blood, I called for one hemostatic clamp after another, firing them blindly into the flooded area for about 30 seconds until, by sheer dumb luck, I finally snapped one onto the open end of the offending vessel. Anxious to get the patient off the table before perpetrating another near-catastrophe, I stitched the wound closed as rapidly as my trembling fingers allowed, not knowing that I should have irrigated it clean of the accumulated pool of blood. I couldn't calm down until the patient was safely in the recovery room. None the wiser — because I didn't dare tell him about the mishap — Dr. Swift discharged Mr. Green the next day, but he was readmitted a week later with a high fever and a large wound abscess caused by infection of the retained blood. It was another four days before he had recovered sufficiently to go home.
When Mr. Green put his trust in Dr. Swift by signing the operative permit, he was only dimly, if at all, aware of how complex an agreement he was entering into and how many levels of responsibility were involved in this apparently straightforward surgical procedure. Almost five decades have passed since that day in the life of an unsuspecting patient, a slick surgeon, and a scared plebe, and much has changed — but much also remains the same.
A surgical team is a small cohort of highly trained persons who come together for a specific and hazardous task requiring the utmost in group interaction and the interplay of shared responsibilities. An operation is an exercise in trust. The surgeon must assure himself that all members of the team are up to the demanding performance expected of them at that specific time and under those specific circumstances. This means that he is putting his trust in the hospital where he works, the system by which the group has been assembled, and all the people bearing even peripheral responsibility for the success of the undertaking, whether or not they work under his direct supervision. These people include men and women who are not actually on the team, whose duties are performed far away from the operating room. Some of them he rarely or never meets — such as those who sterilize or maintain the equipment, prepare the instruments, or hire or assign some of his assistants. When patients put their trust into a surgeon or other doctor, they are entrusting their health to a whole array of systems.
Although these systems are replete with compensatory mechanisms by which errors are recognized and corrected, such an intermingled network of interactions will inevitably result in occasional mistakes that elude every safeguard, sometimes cascading into disaster. Thankfully, such catastrophes are rare; under ordinary circumstances, thousands of operations are performed without such an occurrence. Nevertheless, medical error accounts for more than a few of the approximately 4 percent of patients in whom complications of treatment prolong a hospital stay or result in disability or death.
Some errors occur because trust is overtly violated; others result from human fallibility or foibles. Mr. Green was the victim of both types of errors. Dr. Swift should not have left his patient without assuring himself that the assistant was capable of completing the operation safely; some would say that he should not have left at all. I should have disclosed that I was a student — and a brand-new one at that. The nurses and the anesthesiologist should have objected when Dr. Swift announced his intention to leave such responsibility to a novice. Perhaps the senior resident should not have assigned a tyro to assist a surgeon known for his cavalier attitude about obligation to patients. Dr. Swift's office assistants should not have planned his day so inflexibly that a delay would wreak havoc with his schedule and whatever good intentions he had. And having come so close to disaster, I should have overcome my fear of the consequences to myself and told Dr. Swift what had happened. Had a single one of these errors been avoided, the infection might have been prevented.
Sometimes mishaps occur in spite of every precaution, as the result of systemic error. This disembodied cause is emphasized strongly in the current literature, and indeed each person who participates in caring for the sick is beholden to others, who rely on still others, in a chain that extends back to apparently remote realms, where people may be responsible for methods that are beyond the control of those who use them. Various elements of medical care may be carried out according to faulty designs, such as those of our sometimes inadequate methods of drug delivery, information transmission, and equipment maintenance. When such systems misfire, we reassure ourselves that no one is personally at fault. But the outcome — the failure to fulfill expectations — is the same. It may be true that when a failure occurs, the way to prevent its recurrence is not only to improve individual performance, but to review and correct entire systems. And yet individual people will always be our best resource against error.
The complication that affected Mr. Green would be unlikely to happen today — systems of training and clinical care have changed enormously, and so has the role of the surgeon, whose authority was once so absolute that no one dared to question him. But one element that has not changed is the need for watchfulness by each person involved. We may indict systemic error, but we must also be alert to failures of human compensatory mechanisms — the ability of each person along the chain to recognize and correct errors, wherever they may originate.
Source Information
From the Department of Surgery, Yale University School of Medicine, New Haven, Conn.(Sherwin B. Nuland, M.D.)
I was never quite sure whether my temporary title of "sub-intern" was something to be proud or ashamed of. I would have been pleased as punch about it had one of my professors not recently referred to interns as "the Mortimer Snerds of the medical profession." If that characterization was even close to accurate, what was a sub-intern? In my worst moments of self-doubt, usually when I was alone and worriedly trying to solve a problem at the bedside at three in the morning, I would console myself by recalling that I had been authorized by the chief resident to introduce myself to patients as Dr. Nuland — hardly the title of a sub-anything. That kind of deception was commonplace in those days. Believing it to be justified by the necessities of our training and the importance of assuring patients of our competence, we students didn't think of such seemingly harmless fibs as the self-serving lies we later realized they were.
I had been assigned that day to assist one of the senior surgeons in the removal of a large fatty tumor that bulged outward under the skin of a patient's groin. It was hardly a major undertaking, especially since it was being performed by one of the finest — "slickest" was the accolade we used for our most dextrous teachers — operators on the hospital's staff. I'll call him Dr. Swift. Though I had never met him, Dr. Swift's reputation for speed and a certain dashing elegance preceded him. I felt confident that no problems would arise, even when he told me that he was running late for an operation at another hospital, about 10 blocks away. "Doctor, would you mind closing when I've gotten Mr. Green's lipoma out?" he asked. Too excited by the opportunity and too flattered to point out that I was a student in my sixth day at the operating table, I assented happily and self-assuredly, evidently convincing him of both my enthusiasm and my capability. Given the surgical mask on my face, he had no way of knowing that I was 22 years old.
Swift performed the operation as slickly as I had anticipated, handed the specimen to the nurse, and stepped back from the table. Hastily stripping off gown and gloves, he strode through the swinging doors of the operating room, calling out his thanks to the nurses. Over his shoulder, he gave me my orders just before disappearing up the corridor: "And by the way, doctor, just trim away that bit of extra skin to make the closure neat, OK?" He didn't wait for a reply.
I did as I was told, using curved scissors to trim the edges of the wound before beginning to stitch. In the process, however, I inadvertently cut into a large vein just under the skin, lying there as though in wait for my hapless hands. Feeling a bit panicky as the wound quickly filled with dark blood, I called for one hemostatic clamp after another, firing them blindly into the flooded area for about 30 seconds until, by sheer dumb luck, I finally snapped one onto the open end of the offending vessel. Anxious to get the patient off the table before perpetrating another near-catastrophe, I stitched the wound closed as rapidly as my trembling fingers allowed, not knowing that I should have irrigated it clean of the accumulated pool of blood. I couldn't calm down until the patient was safely in the recovery room. None the wiser — because I didn't dare tell him about the mishap — Dr. Swift discharged Mr. Green the next day, but he was readmitted a week later with a high fever and a large wound abscess caused by infection of the retained blood. It was another four days before he had recovered sufficiently to go home.
When Mr. Green put his trust in Dr. Swift by signing the operative permit, he was only dimly, if at all, aware of how complex an agreement he was entering into and how many levels of responsibility were involved in this apparently straightforward surgical procedure. Almost five decades have passed since that day in the life of an unsuspecting patient, a slick surgeon, and a scared plebe, and much has changed — but much also remains the same.
A surgical team is a small cohort of highly trained persons who come together for a specific and hazardous task requiring the utmost in group interaction and the interplay of shared responsibilities. An operation is an exercise in trust. The surgeon must assure himself that all members of the team are up to the demanding performance expected of them at that specific time and under those specific circumstances. This means that he is putting his trust in the hospital where he works, the system by which the group has been assembled, and all the people bearing even peripheral responsibility for the success of the undertaking, whether or not they work under his direct supervision. These people include men and women who are not actually on the team, whose duties are performed far away from the operating room. Some of them he rarely or never meets — such as those who sterilize or maintain the equipment, prepare the instruments, or hire or assign some of his assistants. When patients put their trust into a surgeon or other doctor, they are entrusting their health to a whole array of systems.
Although these systems are replete with compensatory mechanisms by which errors are recognized and corrected, such an intermingled network of interactions will inevitably result in occasional mistakes that elude every safeguard, sometimes cascading into disaster. Thankfully, such catastrophes are rare; under ordinary circumstances, thousands of operations are performed without such an occurrence. Nevertheless, medical error accounts for more than a few of the approximately 4 percent of patients in whom complications of treatment prolong a hospital stay or result in disability or death.
Some errors occur because trust is overtly violated; others result from human fallibility or foibles. Mr. Green was the victim of both types of errors. Dr. Swift should not have left his patient without assuring himself that the assistant was capable of completing the operation safely; some would say that he should not have left at all. I should have disclosed that I was a student — and a brand-new one at that. The nurses and the anesthesiologist should have objected when Dr. Swift announced his intention to leave such responsibility to a novice. Perhaps the senior resident should not have assigned a tyro to assist a surgeon known for his cavalier attitude about obligation to patients. Dr. Swift's office assistants should not have planned his day so inflexibly that a delay would wreak havoc with his schedule and whatever good intentions he had. And having come so close to disaster, I should have overcome my fear of the consequences to myself and told Dr. Swift what had happened. Had a single one of these errors been avoided, the infection might have been prevented.
Sometimes mishaps occur in spite of every precaution, as the result of systemic error. This disembodied cause is emphasized strongly in the current literature, and indeed each person who participates in caring for the sick is beholden to others, who rely on still others, in a chain that extends back to apparently remote realms, where people may be responsible for methods that are beyond the control of those who use them. Various elements of medical care may be carried out according to faulty designs, such as those of our sometimes inadequate methods of drug delivery, information transmission, and equipment maintenance. When such systems misfire, we reassure ourselves that no one is personally at fault. But the outcome — the failure to fulfill expectations — is the same. It may be true that when a failure occurs, the way to prevent its recurrence is not only to improve individual performance, but to review and correct entire systems. And yet individual people will always be our best resource against error.
The complication that affected Mr. Green would be unlikely to happen today — systems of training and clinical care have changed enormously, and so has the role of the surgeon, whose authority was once so absolute that no one dared to question him. But one element that has not changed is the need for watchfulness by each person involved. We may indict systemic error, but we must also be alert to failures of human compensatory mechanisms — the ability of each person along the chain to recognize and correct errors, wherever they may originate.
Source Information
From the Department of Surgery, Yale University School of Medicine, New Haven, Conn.(Sherwin B. Nuland, M.D.)