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The True Cost Of Surgical Mistakes

Fri, 10/16/2009 - 6:04am
Jeff Reinke, Editorial Director
For an article appearing in the October issue of Surgical Products, I spoke, via e-mail, with Soham Roy, MD, FACS, FAAP. One of the areas our dialogue covered was how to deal with the aftermath of these incidents, as well as the right strategies for operating room personnel in helping to prevent them. Instead of trying to wax poetic or paraphrase, I thought his exact words were so powerful that they deserved to be shared just as he expressed them, as their impact goes well beyond any one topic.

For an article appearing in the October issue of Surgical Products, I spoke, via e-mail, with Soham Roy, MD, FACS, FAAP. One of the areas our dialogue covered was how to deal with the aftermath of these incidents, as well as the right strategies for operating room personnel in helping to prevent them. Instead of trying to wax poetic or paraphrase, I thought his exact words were so powerful that they deserved to be shared just as he expressed them, as their impact goes well beyond any one topic.

“Every good surgeon I know carries around his or her adverse outcomes deep in their souls until the day they die. However, every GREAT surgeon I ever trained under looked closely at those patients who had complications or adverse outcomes and tried to learn as much as possible from them to prevent a similar complication or bad outcome from ever happening to another patient.

“I have personally forgotten the names of the thousands of patients who had uneventful surgeries and uneventful, expected outcomes. However, I could immediately list the names of each of those patients who ever had an unexpected complication or setback in addition to describing exactly what went wrong and why.

“I suppose I remember them all and try to learn as much as possible from what happened, and use that to prevent it from happening again in the future. The key is to try to make sure that it never happens to another patient again, based on what the entire team has learned as a result of that experience.”

My original thought was to try and relate these occurrences to things I’ve experienced in a life led completely outside of the OR, and away from the pressures of holding a person’s life in one’s hands. In the end, my experiences in high school sports, professional meetings and my personal life simply can’t compare to what surgeons, nurses and other surgical team members must endure in dealing with incidents that can range from wrong site surgery to a retained object to a surgical fire.

I guess the primary thought I’d hope to convey is that whether we make mistakes on the operating table or in other areas of our lives, the greater individual tragedy would stem from a failure to learn from them. Granted, this may not provide immediate solace or peace of mind, but as Dr. Roy mentions above, it’s this ability that separates the good from the truly great and represents a focus on those that can be helped in the future instead of those incidents that, regardless the amount of guilt or self deprecation, cannot be changed.

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