Study: Busy Surgeons Pose a Risk to Patient Safety

By John Palmer

A recent report from medical liability insurer Coverys takes a close look at whether busy surgeons lead to more malpractice claims and a risk to patient safety.

Considering that the United States performs more than 48 million surgical inpatient procedures and more than 35.8 million surgical outpatient procedures, the risks are high that overtaxed and overtired doctors will make mistakes. These occur through lack of judgment, performance errors, or preparation errors.

In addition, it’s estimated that Americans will undergo an average of nine surgical procedures, of varying severity, during their lives. This means there’s a good chance that many of these patients will at some point be a victim of surgical malpractice.

“In an era of productivity and profitability, surgeons and their support teams are challenged to do more with less time,” wrote Ann Burke, RN, CPHRM, CPPS, senior director of risk management for Coverys. “And those pressures can have patient safety consequences.”

The report from Coverys takes a look at five years of closed medical malpractice claims data from 2014–2018 to provide insight into the root causes of surgery-related claims and evidence-based recommendations to help mitigate future risks in the delivery of care.

Some of the major findings of the report include the following:

• Surgery—and the care and decision-making leading up to and following surgery—was the second most common cause for medical malpractice claims overall.
• The top surgical specialties to trigger claims were general surgery, orthopedic surgery, and neurosurgery, which made up 50% of surgery-related malpractice claims. Of those, general surgery (22%), orthopedic surgery (17%), and neurosurgery (8%) made up the top three.
• The vast majority (78%) of allegations were related to practitioner performance during surgery.
• Among closed claims over the five-year period with a surgical allegation, 29% of surgery injuries were “permanent significant” injuries or worse, with 9% resulting in death.
• 27% of surgical claims alleged a failure in clinical judgment and/or communication.
• Physicians were more likely to have an alleged failing of technical skill (39%) than their advanced practice provider counterparts (26%).

The report, titled Surgery Risks: Through the Lens of Malpractice Claims, was released in February and written by Burke, as well as Sharon Gilmore, MHA, BSN, RN, CPHRM, CPHQ, Coverys’ senior risk specialist of risk management, and Maryann Small, MBA, the company’s director of data.

This is the fifth report in the company’s “Dose of Insight” series, which has previously explored medication errors, errors in the ED, diagnostic accuracy, and obstetrics, and offered suggestions on how to improve the areas under examination.

“Every day in the United States, tens of thousands of surgical procedures are performed, most without major incident but all with inherent risk for poor outcomes,” the authors concluded. “At Coverys, we believe that the stories within the data from claims that arise out of surgery are signals—beacons of hope, signs of vulnerability, and clues for continuous improvement.”

What causes claims?

According to the Coverys report, one-quarter (25%) of malpractice claims are caused by surgery, and of those, more than three-quarters (78%) are caused by performance errors, which came in as the overwhelming cause of claims. For comparison, retained foreign bodies, the closest competitor for the top spot, came in at 7%.

Surgical errors can result in dramatic injuries and cause a lifetime of suffering, both physical and financial. The Coverys report found that almost a third (29%) of surgical errors resulted in permanent significant injuries or worse, with about 9% resulting in the patient’s death. That’s not to negate the less significant injuries—a full 31% of the total were found to suffer from injuries characterized as “temporary major.”

“Practices and practitioners involved in the discipline and art of surgery must be devoted to patient-centered care because no amount of surgical skill or good judgment can replace comprehensive understanding and active participation on the part of the patient or their family,” the report concluded.

That being said, 27% of the surgical claims analyzed came from alleged failures in judgment or communication between surgeon and patient. Of the 2,521 issues studied, 39% were found to come from technical skill errors, with clinical judgment errors coming in second at 17%, followed by communication errors at 10%.

“If they are not truly informed, properly assessed, ready physically and emotionally for their surgical procedure, fully heard, or willing and able to comply with preoperative and postoperative instructions, the final outcome can fall short of the patient’s expectations,” the report concluded.

In other words, surgeons and team members should make time to communicate with patients, explain to them every step of what is about to happen, inform them clearly of their responsibility for their own recovery, and be a larger, more personal part of the surgical experience.

“From the staff who are afraid to speak up to a surgeon, to the ad hoc surgical teams that are sometimes assembled at a moment’s notice, to the many players who sometimes fail to fully document patient history, care, or surgical notes—communication failures during surgery and at any point during the episode of care can negatively impact a patient’s outcome,” the report authors concluded.

Recommendations for improvement

The report identifies several themes and patterns in surgical claims that could be used as a model to help improve outcomes.

Get better at patient handoffs. This falls under the communication umbrella. Yes, surgeons are busy, and they can’t handle everything. But they do need to coordinate their teams and make sure the team members understand every part of the surgery and what needs to happen before and after the procedure to ensure success and safety. Coverys says that “from preoperative to operating room, to postoperative, hospital floor, home, or rehabilitation center, as well as follow-up with other providers, successful handoffs must be well-organized with thorough instructions, clear communication, and adequate documentation.”

Identify and care for at-risk patients. The Coverys report identified several instances where injuries or errors were caused by a failure to advocate for patients at risk, either because consent forms were not in their native language, or because they were elderly and did not have a capable caregiver at home, or because they suffered from a comorbidity that required a change to the surgical plan.

“Some patients feel judged or embarrassed because of their lack of health literacy, so they don’t ask vital questions that impact their medical care,” the report authors wrote. “Great strides can still be made to develop and execute processes and scripts for explaining the nature of a surgery—and the risks, benefits, or alternative(s) to it—and subsequently ensuring patient understanding.”

Minimize distractions. There is a reason the aviation industry is identified as one of the safest. During certain stages of flight below 10,000 feet, pilots are governed by an FAA regulation known as the “sterile cockpit,” a distraction-free zone during which no non-essential personnel or duties are allowed.

Coverys recommends that surgeons do the same in their operating rooms. In too many of the surgical claims studied, surgeon distraction was cited as a cause, ranging from loud music playing, to people taking phone calls during the procedure, to people coming into the room unnecessarily and causing disturbances.

John Palmer is a freelance writer who has covered healthcare safety for numerous publications. Palmer can be reached at johnpalmer@palmereditorial.com.