Thursday, November 21, 2013

Patient falls off OR table: System error or human error?

An anesthetized patient fell to the floor headfirst from an operating room table during a laparoscopic appendectomy in Scotland. The table had been tilted into an extreme head down position to facilitate the operation. Fortunately, no injury occurred.

The Edinburgh Evening News account says that there were 10 staff members in the room at the time the case started, but no one had placed a safety restraint on the patient.

A follow -up story noted that the hospital has experienced 11 other major surgical errors in the last year including two instances of wrong-site surgery and a case in which five swabs were left inside a single patient.

An investigation by the hospital noted that the level of situational awareness of the operating room staff was inadequate, and teamwork and communication were poor. In addition, the safety culture within the operating room was described as not highly attuned to patient safety.

The staff was also distracted by mobile phone use and idle chatter.

Instead of addressing the obvious human errors such as failure to place the safety strap, which in US hospitals is clearly the duty of the circulating nurse, the hospital's plan of correction focused on the following typical system-type corrections:

Compulsory training of 1200 staff. Although there were 10 staff for a laparoscopic appendectomy (in the US there would be 4, nurse, scrub tech, surgeon, anesthesiologist), I doubt that there are 1200 people working in the operating room of this 570-bed hospital. What will those not working in the OR have to gain from compulsory training? I wonder if anyone considered that 10 staff for an appendectomy is far too many, and that's why there was a lot of idle chatter. Six of the staff had nothing to do until the patient needed to be picked up off the floor.

A ban on talking at key times during operations. This one will be hard to enforce. Who decides what the key times are? I also don't see what it had to do with the incident since tilting the table would not be considered a key time in the case.

Daily meetings to improve patient safety. Good luck with that. What on earth are they going to discuss at daily meetings to improve patient safety? I predict that those meetings won't take place for more than 3 or 4 weeks.

Sanctions for staff who fail to meet the new standards. Also be hard to enforce. How will this be judged?

I would have talked with the nursing staff and asked them whose job it was to place the safety strap. If you want to make a system change, why not clearly specify which staff member is responsible for that action? And how about using a checklist?

Five years ago, the Scottish Patient Safety Program recommended using pre-surgery meetings and checklists to protect patients. The investigation showed that in this hospital, checklists were completed about 10% of the time and often not properly. The staff claimed that they didn't have time to do the checklists. Ten people in the room for an appendectomy and no one has time to complete a checklist?

Next I would have asked the anesthesiologist where he was. Usually the job of adjusting the table is his, and the controls are at the head of the bed. He should have noticed the patient was beginning to slide off the table and intervened.

Finally I would have asked the surgeon just how much head down tilt he needed. I have never even come close to having a patient more than about 30 degrees of head down during a laparoscopic appendectomy.

Patient falling from an OR table—human error.
Wrong site surgery—human error.
Leaving foreign objects inside patients—human error.

The OR staff of every hospital counts instruments and swabs. Wrong-site surgery is 100% avoidable. This hospital had a number of appropriate systems in place. The staff simply disregarded them. Creating more meetings and rules that are unlikely to be followed or make a difference will not solve the problem of a staff with a "can't do" attitude.


Anonymous said...

I don't disagree with your analysis, but I am puzzled about a few things.

Systems are put in place partially to offset propensity for errors in individuals. Most OR's require table straps and time-out's. If these are ignored, isn't that a systems problem?

For example, from what I see during a significant number of time-outs, the surgeon or anesthesiologist are doing other stuff instead of facing the nurse announcing the time-out. Isn't it a systems problem that the process can be so easily overridden?

Combining this with the recent discussion on how hospital ratings are useless, I am left wondering why medical practice should be left with no benchmarks. We are supposedly a science-based field. Yet many of us keep insisting that practitioners rely only on their own particular experiences and idiosyncrasies.

Skeptical Scalpel said...

Anon, thanks for commenting. I see your point, but if you have personnel who don't obey existing rules, how does making more rules solve the problem? I would reprimand those who didn't apply the safety strap and others such as the two who left 5 swabs out of their count.

Apparently, this entire OR crew is going to need to be watched closely. Supervisors will need to get off their butts and cancel some meetings to free up time to directly observe their people in action and enforce the existing rules. If that doesn't work, they need to hire new employees, not create more plans of correction.

I agree that surgeons and anesthesiologists often don't take time outs seriously. They need leaders who buy into the process and strong levels of supervision too.

Libby said...

Human's implement the system so it is human error. The system cannot make decisions, humans do and humans decided to ignore safety and system guidelines, never mind common sense ("gee, maybe we oughta tie this dude down so he doesn't end up on my lap").

[on an irreverent note, "Who WD-40'd this table?"]

Skeptical Scalpel said...

Libby, thanks for commenting. I agree it's usually the humans, especially the ones who oil the table.

Anonymous said...

The ones who oil the table? Would those be the lawyers?

Skeptical Scalpel said...

Lawyers or their agents.

Hawk doc said...

10 persons for a lap appy. No wonder there was chaos in the O.R.
Patient saftey is the utmost priority.

Hawk doc said...

10 persons for a lap appy. No wonder all that chaos in O.R. leading to the mistakes.After all the surgeon is the captain. The buc stops there.

Skeptical Scalpel said...

Hawk, I agree 10 seems like a lot of staff. Surgeon is ultimately responsible. I don't see why he would have needed so much table tilt that the patient fell off.

dayna said...

The number of staff in the room isn't really the problem, yes it could contribute....but we don't know who they were. Nursing assistant, Anes. tech, student, surgical assistant, resident, orientee? The problem is most likely from what I see in OR's every day...the pairing of two inexperienced persons (circulator and scrub) as a team for the day. THIS is not acceptable in my opinion. You can't know what you don't know when you have 6 months of OR time under your belt. It would be nice if everyone in the room knew everything (ha!) or had the experience of being there for "near misses" But when you pair brand new people together there can be significant lapses in the "what to look out for" factor. IMO, that should be policy in EVERY operating pair experienced with non-experienced . I feel that would limit errors and at the very least help those with less experience to learn from those that are.

Skeptical Scalpel said...

dayna, you make a very good point. OR supervisors please note.

Anonymous said...

This is a system error. If you apply the James Reasons approach, there was no apparent intentional negligence.
The blunt end has policy, the sharp end is where there has no be constant mindfulness.
1. Expect the unexpected
2. do not oversimplify
3. be sensitive to operations
4. defer to expertise
5. be resilent

Skeptical Scalpel said...

You say the negligence wasn't intentional. That's true. Would you call it a slip, a lapse, or a mistake (all terms used by James Reason)? Was it a slip--an omission due to attentional failure? Or maybe a lapse--omitting a planned item (the strap)? Or was it a mistake--based on lack of knowledge.

What ever you call it, the system requires a patient on an OR table to be strapped in. It wasn't done by the 10 staff in the room. How would you redesign the system so this could never happen again? Personally, I don't think you can answer that.

Anonymous said...

I had a patient fall off the table during a prone I&D perirectal. It was the end of the surgery and I was asked to get the bed. We all know that you want a bed in the room quickly at the end of a prone case to prevent issues! This pt had sedation (deep). When I went out of the room the surgeon was on one side of the pt and the anesthesiologist was at the head. When I was entering the room no one was facing the pt and he was starting to push himself off the table, to which I could only yell. The only thing that prevented major injury was that I placed a thigh strap on him. And in the end after our root cause meeting the only thing I could figure to prevent this in the future was to physically tell someone to watch the pt because I had a false sense of security before, thinking we were all thinking the same is going to wake up and either have breathing issues prone or start to try to get him, keep him safe! And as a side note I have to disagree with the whole surgeon is captain comment! Surgery is like a symphony, it is a team effort! Everyone has their duties, but the end result is that the pt comes through safely and hopefully better than before! So any surgeon still thinking they are the captain should get their head out of their butt! While their insurance may pay out the most on an error, everyone in that room is responsible! We are all captain's at different points in the surgery; the best thing is to know your part and that it is just as important as the people cleaning the room when you are done, as they are helping to prevent infection on that next patient! Ok, I'm done with my rant! signed an RN circulator!

Skeptical Scalpel said...

Anon, thanks for commenting.

I had a similar experience once with a patient who was prone for a pilondal cyst excision. In the middle of the case he woke up and tried to leave the room. Luckily, he too did not fall from the table.

I agree completely with your opinion about the surgeon no longer being responsible for everything that happens in the OR or anywhere else for that matter.

If you haven't read this post ( from 2012, you should. Take a look at the comments too.

Ben said...

Presumably someone filled in an incident report afterwards:)

Skeptical Scalpel said...

I would hope so, but it wasn't me. I didn't play the incident report game.

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