What actions should be taken when a cardiothoracic surgeon (cardiothoracic surgeon) ligates and cuts an important vessel during an operation, attributing the error to distraction caused by the presence of a phone and a person, likely a observer or assistant, in the operating room?

From the Guidelines

The most appropriate action in this case is to conduct a root cause analysis (option c). When a serious medical error occurs, such as the incorrect ligation of an important vessel during surgery, it's essential to systematically investigate the underlying factors rather than immediately implementing punitive measures. A root cause analysis would examine all contributing elements including environmental distractions (phones and pagers), communication breakdowns, procedural issues, and systemic factors that allowed the error to occur. This approach is supported by the concept of a 'sterile cockpit' in the anaesthetic workplace, which suggests that non-essential conversation and communication can be distracting, leading to errors 1. The study published in Anaesthesia in 2021 highlights the importance of minimizing distractions during critical phases of procedures, such as induction and emergence in anaesthesia, which can be analogous to critical phases in surgery 1.

Some key points to consider in the root cause analysis include:

• Environmental factors: The presence of phones and pagers in the operating room can be a significant distraction, and protocols should be developed to manage their use during surgical procedures.
• Communication breakdowns: The analysis should examine how communication among the surgical team could be improved to prevent similar errors.
• Procedural issues: The root cause analysis should review the surgical procedure itself to identify any potential flaws or areas for improvement.
• Systemic factors: The investigation should also consider broader systemic factors, such as staffing, training, and hospital policies, that may have contributed to the error.

By taking a comprehensive and systematic approach to investigating the error, healthcare providers can identify and address the underlying causes, ultimately improving patient safety and reducing the risk of similar errors in the future.

From the Research

Possible Actions

• Suspend his license: There is no direct evidence from the studies provided to support suspending the license of the cardiothoracic surgeon 2, 3, 4, 5, 6.
• Prevent phone and pegar in the operative room: While the presence of distractions such as phones in the operative room may contribute to errors, there is no study that directly addresses the prevention of phones and pegar in the operative room as a solution to the problem 2, 3, 4, 5, 6.
• Cause root analysis: The study by 2 suggests that Root Cause Analysis (RCA) is an effective tool for improving patient safety and quality improvement in hospitals. Conducting a root analysis may help identify the underlying causes of the error and prevent similar incidents in the future.

Considerations

• The study by 3 highlights the importance of analyzing risk factors for blood and body fluid exposures in operating rooms, which may be relevant to the incident involving the cardiothoracic surgeon.
• The studies by 4, 5, and 6 provide insights into surgical site infections, enhanced recovery after surgery, and the role of surgery in global health, but do not directly address the issue of distractions in the operative room or the actions to be taken in response to the incident.