By Dr. Lorraine LeGrand-Westfall

The effectiveness and safety of surgery has steadily improved over the last many decades in Canada. Despite these significant advances in surgical care, patient safety incidents do sometimes occur. With over one million surgical procedures performed annually in Canada, there remains a commitment for ongoing quality improvement.

At its core, surgical care is about teamwork. It occurs in a highly complex environment that requires finely-tuned processes and tools, and skilled individuals who collaborate and communicate in the best interests of the patient. Much like Formula 1 racing is about more than just driving the car, surgical care is about more than just the procedure. In Formula 1, hundreds of people make up the team including technical and commercial experts, designers, aerodynamicists, R&D, mechanics and more.

Similarly, surgical care relies on a team of highly skilled physicians, nurses, anesthesiologists, and operating room personnel working together to manage a highly complex and dynamic environment. The tools and technology employed are incredibly sophisticated. Training is crucial, particularly as technology and procedures are constantly evolving. No step is too small in terms of preparation, coordination, checking, double-checking, clarifying expectations, and managing potential obstacles and a changing environment. Collaboration and clear communication between team members, all while keeping the patient at the center, are essential to ensure safe delivery of care.

A recent detailed review of medical-legal cases in Canada between 2004 and 2013, explored the issues related to surgical care safety incidents. This review was conducted by The Canadian Medical Protective Association (CMPA) and the Healthcare Insurance Reciprocal of Canada (HIROC), who combined their medical-legal data related to surgical safety incidents collected over that 10-year span to produce a retrospective analysis. The two organizations, along with the Canadian Patient Safety Institute (CPSI), are now using the findings to advocate for extensive system and practice improvements.

In their analysis, the organizations identified 1,583 CMPA and 1,391 HIROC medico-legal cases involving an in-hospital surgical incident. Peer expert reviews identified system and provider issues in 53% of CMPA and 49% of HIROC surgical incidents. Almost two-thirds of cases involved non-oncology/non-trauma repairs or excisions (e.g. inflammation and infection). Trauma-related care represented 12% of CMPA and 3% of HIROC datasets. Oncology-related cases represented 14% of CMPA and 8% of HIROC datasets.

Patient harm (i.e. physical and psychological outcomes) involved injury to organs, blood vessels or nerves; wrong surgery (wrong body part, patient, procedure); unintended retained foreign bodies; hemorrhages; or burns. Retained foreign bodies or wrong surgery were identified in 12 per cent of CMPA and 18 per cent of HIROC surgical safety incidents. System factors, including an inadequate, or non-adherence to a surgical safety protocol, were also found to be key contributors to surgical safety incidents.

Learning from the analysis

CMPA and HIROC delivered a number of recommendations to address system, physician, and other healthcare provider factors. Some of these included:

• Implementing standardized protocols (e.g. surgical safety checklist) to support inter-disciplinary team situational awareness (i.e. keeping track of what is happening and anticipating what might need to be done) and improve verification practices (e.g. patient, site, procedure, and count).
• Performing a comprehensive patient assessment, and obtaining and documenting an informed consent.
• Adopting strategies to identify and mitigate cognitive biases.
• Ensuring all standard and non-standard items are counted (e.g. sponges, towels, packing, needles, instruments, and items “too large/obvious” to be left behind); separate the sponges to view them concurrently; ensure all new items added during surgery are documented.
• Employing self-reflective practices to allow for clinical improvement and shared learning.

The CMPA believes that improving surgical safety culture requires the cooperation and commitment of the entire healthcare team in the adoption of reliable care processes and continued practice improvement. All healthcare professionals need to be engaged and advocate for the development of safe systems of care.

The report, Surgical Safety in Canada: A 10-year review of CMPA and HIROC medico-legal data, is available at: www.cmpa-acpm.ca/system-and-practice-improvement.

Dr. Lorraine LeGrand-Westfall is a surgeon and Chief Privacy Officer and Director, Regional Affairs with the CMPA. We would like to acknowledge the contributions of HIROC and CMPA’s Medical Care Analytics team.