Invited Commentary

Patient Safety: Invited Commentary

M. Blair Marshall, MD
Chief, Georgetown University Hospital, Department of Thoracic Surgery
Chair, The Society of Thoracic Surgeons Workforce on Patient Safety

I appreciate the opportunity to contribute this commentary. Surprisingly, despite the invitation, I have been reticent to write. This is not because I was preoccupied with other tasks but that the subject makes me uncomfortable. We work hard at obtaining the best outcomes for our patients; acknowledging that we err can be a challenge.

Historically, surgeons have been the greatest champions for safe and quality care. In the early 1900s, Dr. Ernest Codman, a surgeon practicing at Massachusetts General Hospital, began efforts to improve outcomes across hospitals in the United States.  His conclusions supported standardization across institutions to improve patient safety, a term not yet coined. This work was recognized by the American College of Surgeons and subsequently supported through a sub-committee of the same organization. This eventually became the Joint Commission on Accreditation of Healthcare Organizations -now The Joint Commission - the largest healthcare accreditation body in the United States.

Like Dr. Codman, many of my colleagues are great champions for the best care for their patients. The Society of Thoracic Surgeons (STS) likely did not fully anticipate the vital role the STS National Database plays in the best care of our patients, its impact on healthcare today and for the future. Outcomes, in the form of morbidity and mortality, are fundamental to the practice of surgery. By continually examining our results and identifying areas for improvement, we have been able to improve and provide safer care. Along with other advancements in medicine, the complexity of procedures performed has increased greatly while the morbidity and mortality associated with them has concurrently decreased. The constant increase in complexity and the introduction of new procedures and technology increases the potential for error.

Despite our demonstrated excellence in care, the Institute of Medicine reported 44,000-98,000 deaths occur each year due to errors. This number is sobering. It is estimated that 30-50% of errors occur in the operating room. This is not surprising given the complexity and acuity of events. With enhanced focus on patient safety, we have learned more about providing the best care. Errors resulting in harm may be the consequence of the interaction of many disciplines. Surgeons traditionally self blame for adverse events occurring in our patients. We accept all responsibility as the leader of the team and often change what we do to prevent similar events in the future. The fact that we, or others, could be set up for failure by systemic issues is a concept that is not natural to us. To make progress in patient safety, we need to appreciate the relative contributions of many factors as they relate to events that occur. We need to recognize how specific interactions work to prevent errors or encourage recovery from errors. We work in a complex environment where interactions between practitioners, machines, patients, and other non clinical staff can all have an impact on safety and ultimately, outcomes.

Before becoming involved in patient safety, I would have not thought of how the human factors related function of an intravenous pump could set  nurses up for success or contribute to their failure, or how clutter and electrical cords on the floor of an operating room lead to frustration, delays, and impact operative performance. As well, I had not contemplated how systems, machines, and personnel could be optimized to encourage recovery from error.

The relative impact of institutional culture, communication, human factors, and latent failures are critical to our understanding of how to provide better (safer) care. Our knowledge is just emerging as we learn from industries, such as aviation and other high reliability organizations where error rates are necessarily extremely low. Well functioning teams have the ability to recover from error. Likely, we have all witnessed this.  But, as it did not carry the same magnitude as harm to a patient, we may not have acknowledged it.  In our specialty, the pioneering work of Marc DeLeval, MD, Thor Sundt, MD, Paul Uhlig, MD, and others have begun to teach and encourage us to address issues related to safety. Work in this area is a challenge. Fortunately, many of us chose this specialty because that is exactly what we like, a challenge. Addressing patient safety requires changes in culture, problem solving with multidisciplinary approaches, breaking down silos and working with our colleagues in nursing, anesthesia, human resources, administration, and others to make the care of our patients safer.

I very much appreciate the efforts of my colleagues and STS staff, both past and present, whose efforts have resulted in readily available Patient Safety Resources and the Cardiothoracic Surgery Checklists and others. Guidance from the Council on Quality, Research, and Patient Safety has proven invaluable. I look forward to our future efforts, as we, cardiothoracic surgeons, continue to provide safer care for our patients.

Please e-mail patientsafety [at] sts [dot] org with your feedback or suggestions.