Mistakes During Surgery

When it comes to surgery, many of us probably don’t worry about the surgical errors that are the hardest to prevent. These include having the wrong surgery, incomplete surgery, unnecessary surgery, or failing to have surgery when it’s needed. Getting a second and even a third opinion is probably the best way to guard against these problems.

One problem with trying to prevent a mistake once you are in surgery, is that, most likely, you will not be awake to keep an eye on what is happening. I have a friend who recently had surgery in Mexico, and she took along another friend who is a registered nurse. Her surgeon allowed the nurse/friend into the operating room to watch, which was great, but this is not something that is likely to catch on with cancer surgeons in the United States.

The best way to prevent a mistake during your cancer surgery is to choose your surgeon carefully.

• Choose a surgeon who has the right training.
If you have a gynecological cancer, for example, your surgeon should be a gynecologic oncologist, a doctor with years of specialized training in the diagnosis and treatment (including surgery) of these cancers. If you have prostate cancer, your surgeon will probably be a urologist who has advanced training in prostate cancer surgery.

• Choose a surgeon who has adequate experience.
You want a surgeon who frequently performs the procedure you need, and who has done it enough times in his or her career to be really proficient. Ask your surgeon how many of these surgeries he or she has done and how many he or she does each year. For prostate surgery, the answers should be at least 150 in total and at least 15 per year, according to Dr. Paul Lange, chairman of the Department of Urology at the University of Washington and the author of "Prostate Cancer for Dummies."

•Ask for referrals.
This is the time to cast your net widely. Ask for referrals from your doctor and from other people who have had cancer surgery. Look up the surgeons you are considering on the Web. See what research they have published. See what people on cancer bulletin boards are saying about them. Weigh this information based on how reliable it is—the opinion of the woman who happened to be standing behind you in line at the grocery store should have less weight than the opinion of your family doctor, for example.

•Interview several surgeons.
Once you’ve gathered and evaluated referrals, you are ready to interview surgeons.

Make an appointment specifically for this purpose. During the interview, ask your surgeon if he or she will be performing the surgery, or if it will be done by a resident (a doctor in training) under the surgeon’s supervision. Personally, I don’t want a resident practicing on me; I want the surgeon I have carefully chosen. But I am OK with a resident assisting during surgery.

You might ask, “Are any residents going to be involved in my surgery, and, if so, what will they do?” If you do not feel comfortable about what the residents will be doing, say so.

Typically, at a teaching hospital, such as a university hospital, residents are part of the surgery team. If you absolutely do not want residents involved, one surgeon suggests, then you may want to reconsider whether you want to get your care at a teaching institution.

Once you’ve chosen a surgeon you like and trust, you can help prevent errors by making sure that you know about all preparations you are supposed to make before surgery, including discontinuing certain medications. Get these instructions in writing, and make sure you understand and follow them.

Also get clear instructions for what you can expect after surgery. These may include limits on what you can eat, how much weight you can lift, or how soon you can have sex. These instructions should include some idea of when you can return to work or when you should feel “back to normal.”

If you have a clear understanding of what is supposed to happen before, during and after surgery, you will be able to question anything that doesn’t seem right. Don’t be afraid to ask “stupid” questions. And don’t be afraid to call your surgeon’s office even if your question can’t be articulated beyond, “Something doesn’t feel right.”

With surgery, because you probably will be under anesthetic for the procedure itself and woozy afterward, you may want to have someone with you to act as your advocate. This person should have copies of all the instructions you have been given and should be prepared to discuss any problems with your doctor or nurses.

Then, go ahead and mark your body with a pen, if you like. Dr. Ben Anderson, a breast cancer surgeon at the University of Washington Medical Center, says, “I am fine with the patient's writing on herself to verify the laterality of the operation. There is no harm, and [there is] potential benefit for everyone. In our hospital, we have a detailed check and re-check system in the preoperative holding area and in the operating room, including a required ‘time-out’ where the team stops to verify patient identification, operation, allergies, and preoperative drug administration.

“In addition,” he says, “the operating surgeon is required to put his or her initials on the patient to mark the correct operative side. I do not think we can be too careful.”

@ Jeanne Sather 2006

Comments

[Sid Schwab]

When I do readings of my book, I solicit questions, and one I always get is how to choose a surgeon. It's a tough one, and this post implicitly highlights the difficulties. I agree with most of what you've said. And yet: putting strict numbers on how many a surgeon has done of an operation may not be all that useful, if he's done them wrong every time. So I'd not emphasize that one, even though I've been around long enough that I'd come out on top, numbers-wise. For those with a family doc that they know and have reason to trust, I think trusting that doc to make a referral to a worthy surgeon is perhaps the best way to feel comfortable. Along with meeting the surgeon and deciding how you respond. And whereas I've always encouraged second opinions, and have never been offended (well, almost never) when a patient wants them, I also think that if you feel what the surgeon is telling you makes sense and you've asked all the questions you have and have received what feel like thorough and sensible responses, I think more opinions aren't at all mandatory.

Having an advocate of some sort in the OR is, in my opinion, a really bad idea, unless that person is really experienced. Even then, it can be a distraction and a form of pressure that the surgeon doesn't need, especially in a tight situation. I encouraged people to be with my patients when I did certain operations under local anesthesia: breast biopsies, etc. But in a big-deal operation in a big-deal operating room, I'd personally not like it. And I don't think that makes me a bad surgeon.

As to wrong operation/wrong side mistakes. The good news is that publicity in the past couple of years has led to measures that make it nearly impossible now; but marking yourself is a great idea. In fact, you're likely to get marked whether you do it yourself or not. Finally, having been both in academic centers and in community hospitals I can say that location per se isn't that important: there are excellent and not so excellent surgeons in both settings. In the end, being confident in your referring doc, and trusting your internal alarms when you meet the surgeon are probably the best methods.

[Jeanne]

Hi Sid--thanks for adding your thoughts on this topic.

I do take your point on the number of times a surgeon has done a particular operation not meaning much if he/she has done it wrong every time!

I don't expect that people will really take someone with them into the OR ... I think you have to do all your checking on the doctor before you get to that point.

One thing that continues to bother me is that residents might perform the actual surgery at the university hospital without the patient being told beforehand. How do you feel about that? I spent a lot of time choosing a good surgeon, and I want that doctor to do my surgery, not his student.

Jeanne