The Challenges and Opportunities for Reducing Risk in Surgery by William Berry, MD Dr. Berry is board certified in General Surgery and Surgical Intensive Care. He is the surgical consultant to CRICO/RMF and is a faculty member of the Institute for Healthcare Improvement.

Surgery is fraught with risk, a risk that is borne out in the malpractice experience. Consider the very nature of surgery, grounded in science but practiced as an art. It requires dexterity, physical stamina, knowledge, and judgment. In the operating room, relatively “normal” patients are given medications that stop them from breathing and make them feel no pain while a surgeon takes a knife and opens the body, reaching within it to remove a tumor or repair a broken body part. The inherent danger is magnified by numerous other factors, including:

• the ever expanding amount of surgical knowledge that “specializes” even general surgeons,
• less invasive technologies have moved what was once confined to the operating room to the radiology suite or cardiac catheterization laboratory, and
• rapidly advancing technology and new learning curves that challenge surgeons and systems to keep up.

This, then, is the setting in which Forum explores many different problems surgeons (and their patients) are facing: some with ready solutions…some still unsolved.

While surgeons represent 17 percent of the physicians insured by CRICO, surgery-related cases account for 30 percent of the malpractice claims. This imbalance is attributable to several factors. Each surgical encounter carries with it a greater chance of patient harm than is present in many other areas of medicine. Surgeons depend more on physical skill in their care of patients than many other medical specialists—making technical error a vexing and persistent problem. Finally, training surgeons presents unique challenges. How do you know when a resident surgeon is ready to wield the knife and cut and sew? How do you supervise surgical residents closely enough that patients get safe care, and at the same time encourage the development of independent judgment? Our contributing experts touch on these and other important questions relating to surgical risk and strategies to reduce it.

In addition to myriad individual efforts underway to improve surgical patient safety, are some collaborative efforts coordinated through the Harvard medical malpractice insurance program and CRICO/RMF. In response to issues surfaced in the analysis of malpractice claims-and confirmed clinically in the institutions-the need for change is clear.

• A surgical safety collaborative consisting of the Chiefs of Surgery of the major Harvard teaching hospitals was launched two years ago. Improving communication between everyone involved in surgical care lies at the center of their work. This group has now developed, and is in the process of implementing, a set of triggers to enable better communication between residents and attending surgeons. Progress is being made.
• In November 2007, CRICO/RMF organized a Surgical Summit, attended by surgeons from the Harvard-affiliated institutions (and across the country). Extensive discussions took place regarding teamwork in the operating room, technical error at surgery, informed consent, and “what to do after an adverse event.”
• And, in January 2008, CRICO/RMF and the surgical chiefs endorsed a certification program in Fundamentals of Laparoscopic Surgery (FLS). Successful completion of the FLS program is linked to a patient safety incentive.

CRICO/RMF is also funding research in the areas of surgical outcomes improvement through team training and quality improvement. Surgery can and will be safer for our patients through this important work.