Overview of preventing medical errors and incidents in surgery (surgical safety)

1. Definition of medical incidents and errors related to surgery and procedures

- Medical error: Is a failure to implement a previously proposed plan or a wrong implementation of the plan so the goal cannot be achieved. Sometimes making the wrong plan leads to errors. Errors can also occur when doing the opposite of the plan.

- Harm: Impairment of the body's structure or function or harmful effects arising from an incident that has occurred. Harm includes: disease, injury, pain, disability and death.

- Unwanted events (Adverse events/AEs): Unwanted events or complications/accidents are unintended consequences of medical interventions that prolong treatment time, illness and death.

If the incident is caused by an error, it is completely preventable. According to experts, more than 50% of surgical incidents (PT) are preventable.

2. Classify medical errors and incidents related to surgery

2.1. Classify incidents and errors according to level of danger

2.1.1. Incidents and errors are almost (almost) happening

Errors occur but do not affect the patient due to luck or the timely response of medical staff.

2.1.2. An incident occurred but was not harmful to the patient

- The incident affects the patient but is not harmful.

- The incident affects the patient but is closely monitored to prevent harm from occurring.

2.1.3. The incident is harmful to the patient

- Patients are temporarily affected and need treatment and PT intervention to correct the condition.

- Patients are temporarily affected and need to prolong their hospital stay.

- Affected patients cause frequent harm.

- Patients are affected and need treatment intervention to save their lives.

2.1.4. Death (Consequence of incident leading to death).

3. Causes of medical errors and incidents related to PT

3.1. Cause groups

The popular traditional view is that human errors are caused by individuals such as forgetfulness, carelessness, and negligence, and that individuals must bear full responsibility (fines, loss of honor, lawsuits) when errors occur. The modern view is that systemic factors impact both the individual cause of error as well as the ultimate consequences on the patient. With this approach, when an error occurs, individual errors should be considered more important than detecting system errors for backup purposes. This approach is increasingly accepted. The causes of errors can be classified into the following groups: Due to the organization, due to circumstances, due to the group, due to the individual, due to the nature of the work, and due to the patient.

3.2. Main causes of errors and incidents

- Carelessness/lack of concern.

- Untrained/inexperienced staff.

- Age and health of the “Surgical Team”.

- Lack of communication.

- Wrong diagnosis.

- Employees are overworked and under work pressure.

- Reading the prescription incorrectly or making errors in dispensing the medicine, not making "clear" notes in the medical record or due to a wrong label.

- Lack of tools (checklists) to make sure everything is thoroughly checked.

- The "surgical team" is not really compatible and cohesive.

- Pressure to reduce PT time.

- PT methods require different equipment or patient positions.

- Organizational/working culture.

- Friendly and safe level of working environment.

- Care/monitoring continues after surgery.

- Patient characteristics, especially when the patient is at risk such as obesity, anatomical abnormalities,...

- Misunderstandings between patients and the surgical team due to language barriers: tourists, ethnic minorities, etc.

- Caused by the patient himself: due to consciousness disorder, lack of cooperation.

3.3. Some common situations in practice

- The diagnosis is not accurate/inappropriate, so we are passive in handling the situation.

- Prescribing surgery at an inappropriate time, or choosing an inappropriate method.

- PT preparation is not good.

- Due to the expertise of the surgeon and anesthesiologist, technical errors when performing surgery lead to complications, accidents and other medical incidents.

- Due to irresponsibility and negligent behavior leading to situations where the wrong patient is brought in, the wrong location is determined, gauze/instruments are left behind, the wrong medicine/blood is used, and the machinery and equipment being treated are not properly controlled. Interfering with patients, not closely monitoring patients,...

- Some other situations such as: drug allergy during anesthesia,...