Can intraoperative decisions be diagnostic errors?

Canadian medico-legal data suggest that most in-hospital, surgical patient safety incidents occur during the intraoperative phase.¹ Peer experts² reviewing CMPA surgical cases have criticized surgeons’ intraoperative decisions, which are sometimes of a diagnostic nature. Research has shown that a surgeon’s cognitive and communication skills, and the operating room (OR) culture of safety, can contribute to these intraoperative decisions.

Case scenario: Is there an intraoperative diagnostic error?

³

A 75-year-old man consents to a laparoscopic cholecystectomy to treat worsening symptoms from the presence of cholelithiasis. On the day of the procedure, the general surgeon is on call and running late. He informs the anaesthetist to expect a routine, quick case (his second-last one for the day). When he learns that his preferred 30 degree laparoscope is unavailable, he becomes frustrated and accepts a straight laparoscope instead.

During surgery, the surgeon attempts entry with a Veress needle multiple times without success and then switches to a Hasson technique, allowing access to the abdominal cavity. There he encounters multiple adhesions, with bowel adherent to the gallbladder, resulting in a difficult dissection. When the surgeon detects bilious fluid in the operative field, he attributes it to a gallbladder perforation. After extensive irrigation and observing no further spill, he completes the surgery.

The next day, the patient exhibits fever, confusion, and respiratory distress requiring ICU admission and ventilation. The surgeon discusses the possibility of a bile leak with the patient’s family and obtains their informed consent for the patient to undergo a second, exploratory surgery. A laparotomy reveals a laceration of the jejunum, which the surgeon repairs. The patient continues to deteriorate and dies later that week.

The patient’s family initiates legal action. Peer experts in the case opine that the surgeon did not adequately investigate the source of the intraoperative spill during the first surgery. For this reason, he failed to promptly diagnosis the bowel injury. The CMPA provides a settlement on behalf of the general surgeon.

Intraoperative decisions as diagnostic errors

• Intraoperative clinical decisions are diagnostic if you make them in an effort to explain your intraoperative findings.
• Problems with diagnostic decisions are diagnostic errors when they directly contribute to a wrong, missed, or delayed explanation of the patient’s health problem.

In the case scenario, the surgeon’s intraoperative diagnosis of a gallbladder injury (rather than a bowel injury) was the wrong diagnosis.

Medico-legal cases at the CMPA

Although diagnostic errors can occur throughout surgical care, the CMPA specifically analyzed the intraoperative phase in medico-legal cases. Between 2014 and 2018, the CMPA closed 44 medico-legal matters (civil legal, medical regulatory authority, and hospital) with intraoperative diagnostic issues in a hospital OR. All of the cases involved a surgeon. The most commonly named specialties were general surgery, and obstetrics and gynecology.

Of the 44 cases, all involved a harmful incident or a patient’s healthcare-related death, except for one case with no criticism of the surgeon’s care. The decisions on the matters—made by courts, peer experts, regulatory authorities, or hospitals—reflected criticism of the surgeon in 37 of 44 cases (84.1%), a relatively high proportion. (During the same period of case closure, 52.7% of all CMPA cases had this outcome).⁴ Among the 44 cases, the most frequent diagnostic error was a surgeon’s failure to diagnose an intraoperative injury in a timely manner. In many of those cases, the surgeon received criticism for a deficient intraoperative assessment of the patient.

Risk mitigation: What surgeons should know

• Cognition plays a role

While the causes of diagnostic error can be multifactorial, they often involve cognitive errors by a physician. In the case scenario, the surgeon may have experienced a cognitive bias called “premature closure,” which involves uncritically accepting an initial diagnosis without sufficiently considering other possibilities.

To manage cognitive biases, experts recommend strategies such as practising reflectively.⁵ For surgeons in the OR, this means recognizing when key intraoperative decisions are happening—especially decisions related to unexpected bleeding or variants of anatomy—and asking, “What else could this be?” Canadian surgeon and researcher Dr. Carol-Anne Moulton and colleagues describe these moments as “slowing down when you should” in order to regroup, refocus, and increase attention intraoperatively.⁶

Yet, this may be difficult with a high cognitive load. In the case scenario, the surgeon was receiving calls from the OR, he was running late, and he was frustrated about the factors impeding access to his preferred scope. There was unanticipated complexity related to a difficult entry, significant adhesions, and a difficult dissection. In many of the CMPA cases with criticism of intraoperative diagnostic decisions, the medico-legal record explicitly mentions a difficult or complicated procedure.

Research using OR Black Box® technology is delineating the effects of OR distractions on surgeons⁷and the impact of psychological stress on surgical performance.⁸ When cognitive load is high intraoperatively, surgeons may benefit from carefully assessing their diagnostic needs and even pausing, when possible, to seek more information or a second opinion. In multiple CMPA cases, surgeons received criticism for not consulting an appropriate colleague in a timely manner intraoperatively.

• Intraoperative communication facilitates diagnosis

Surgeons can strengthen their intraoperative assessments by encouraging communication within the surgical team. In the case scenario, for instance, there may have been an opportunity for a surgical team member to question whether the bile was not coming from somewhere else (a subsequent pathology report indicated that the gallbladder specimen was intact).

For teams to speak up, however, they must be in an environment of psychological safety, which flows from trust. Dr. Richard Mimeault, a surgeon and physician advisor at the CMPA, explains that, “When surgeons genuinely engage in behaviours such as surgical checklists, huddles, briefs, and debriefs, they are creating moments that demonstrate trust and openness to team members’ opinions and perceptions, even when they conflict with their own.”

• Your workplace culture may impact patient outcomes

An OR culture in which team members feel trusted, respected, and comfortable speaking up may foster better intraoperative diagnostic decisions and in turn, safer care. Increasingly, research is supporting this connection. For example, a study published recently in JAMA Surgery showed that patients of surgeons with frequent coworker reports of the surgeon’s unprofessional behaviour (such as unclear or disrespectful communication) were at higher risk of postoperative complications.¹⁰

Dr. Fady Balaa, a surgeon and physician advisor at the CMPA, believes that “surgeons play a key role in establishing a safe intraoperative culture” in part “through effective leadership behaviours.” These behaviours include effectively dealing with pressure, supporting surgical team members, and setting and maintaining standards for safety.⁸ When surgeons adopt these behaviours, says Dr. Balaa, “they can harness the collective input of the entire surgical team to inform diagnostic decision-making."

The bottom line

The CMPA’s medico-legal cases show that adverse patient outcomes can be associated with a surgeon’s intraoperative decisions. The cases show further that problems with intraoperative decisions can be diagnostic errors, which are sometimes preventable. To improve your intraoperative diagnostic decisions, strive to practise reflectively, recruit cognitive capacity from others when needed, and enhance information gathering by fostering an OR culture of safety.

References

1. The Canadian Medical Protective Association and the Healthcare Insurance Reciprocal of Canada. CMPA and HIROC; 2016 April. Surgical safety in Canada: A 10-year review of CMPA and HIROC medico-legal data: Detailed analysis [cited 2020May 15].
2. Peer experts refer to physicians retained by the parties in a legal action to interpret and provide their opinion on clinical, scientific, or technical issues surrounding the care provided. They are typically of similar training and experience as the physicians whose care they are reviewing.
3. While this case scenario is based on an actual medico-legal case at the CMPA, certain facts have been omitted, changed, and added for illustrative purposes and to ensure anonymity for the parties involved.
4. This percentage was calculated from 15,190 cases that closed by the CMPA between 2014 and 2018 inclusive with information available for in-depth analysis of safe medical care.
5. Graber ML, Sanchez JA, Barach P. Diagnostic error in surgery and surgical services. In: Sanchez JA, Barach P, Johnson JK, Jacobs JP, editors. Surgical Patient Care. Switzerland: Springer International Publishing; 2017. p. 397-412
6. Moulton CA, Regehr G, Lingard L, et al. Slowing down to stay out of trouble in the operating room: remaining attentive in automaticity. Acad Med. 2010 Oct;85(10):1571-7
7. Jung JJ, Elfassy J, Grantcharov T. Factors associated with surgeon's perception of distraction in the operating room. Surg Endosc. 2019 Aug 27. DOI: https://doi.org/10.1007/s00464-019-07088-z
8. Grantcharov PD, Boillat T, Elkabany S, et al. Acute mental stress and surgical performance. BJS Open. 2018 Sep 27;3(1):119-25
9. Yule S, Paterson-Brown S. Surgeons' non-technical skills. Surg Clin North Am. 2012 Feb;92(1):37-50
10. Cooper WO, Spain DA, Guillamondegui O, et al. Association of coworker reports about unprofessional behavior by surgeons with surgical complications in their patients. JAMA Surg. 2019 Jun 19;154(9):828-34

DISCLAIMER: The information contained in this learning material is for general educational purposes only and is not intended to provide specific professional medical or legal advice, nor to constitute a "standard of care" for Canadian healthcare professionals. The use of CMPA learning resources is subject to the foregoing as well as the CMPA's Terms of Use.