Treating Society's Most Vulnerable

"It's when you're in these chains of errors that things are very dangerous. Usually these are very complicated patients and they are much more likely to have errors . . . [but] it was still very valuable for us to recognize this is the reality, that this is happening."
"[A more collegial, open work environment developed] where nothing can be swept under the carpet."
Dr. Ed Hickey, paediatric surgeon, Hospital for Sick Children, Toronto

Courtesy of SickKids UHN      Two Hospital For Sick Children surgeons

 

Dr. Hickey was the lead author in a study published recently in the Annals of Thoracic Surgery which investigated 524 operations with their related post-operative care over the period of several days, which the paper describes as "flights". Described that way because these surgeries were seen to be metaphorically analogous with air flights and for which Dr. Hickey and his hospital colleagues have decided to use a "threat and error" heads-up-awareness NASA-developed safety protocol for pilot use before take-off.

The space agency's model has been used as a template with obvious appropriate alterations which surgeons operating on patients in the cardiac surgery unit of the busiest children's hospital in Canada, could use in the interests of preventing human error resulting in a chain of mistakes leading to compromised health and even death suffered by children post-surgery. In studying over 500 consecutive heart operations on children the investigators discovered that most patients who died or who suffered brain injuries did so as a consequence of error sequences.

They judged that sequences beginning in the operating room were often amplified by subsequently emerging problems in intensive care, post-surgery. While stressing that the death rate and complications that emerged from the challenges faced by heart surgeons already exists at an "exceptionally low" level, the aviation-type reviews used to make such operations even safer might preserve even some of those few lives that are typically lost; the result of extremely complex conditions exacerbating operative and post-operative survival.

Getty Images   Doctors are looking towards and entirely different industry to test out safety procedures

 

Interest in the survey and the conclusions, however tentatively reached after application of the safety protocol, has been expressed by international colleagues considering the adoption of similar practices. Largely because the number of cardiac arrests among the smallest of very ill patients appears to be diminishing even as a more collegial, open environment in which health workers operate has also developed.

Checklists have been developed and they have now become standard procedures in the operating room, based on checklists of a type done in plane cockpits before take-off. Concomitantly, a surgeon operating out of yet another Toronto hospital has developed a "black box" whose purpose is to record what happens during operations for forensic purposes. No longer, using these methods, do individuals solely bear blame when things go awry; errors are now viewed as a systemic problem.

Weekly meetings take place where the entire cardiac team discusses each surgery, whether successful or less so, in contrast to the hitherto typical practise of holding "morbidity and mortality" rounds, sessions meant to dissect only those cases that ended badly. When the NASA model was applied where a threat could be pinpointed as an unusual feature of a patient's heart condition or even a malfunction of vital equipment, it led to a more useful type of procedure.

Errors occurred, it was found, in 49 percent of cases and slightly over 1.3 percent of children, representing seven patients in total, died. Another 13 suffered brain damage, while 68 went on to develop "hemodynamic lesions", like a weakened heart muscle, or an abnormal heart rhythm. Harmful outcomes were seen to have resulted from chains of errors, with one event leading on to another.