Surgery can be a risky thing to undergo. With the development of modern sanitary practices, the probability of some mishap occurring is far less than it used to be. However, it’s still possible for infections or mistakes to take place. What are the chances of either of these happening? How are they usually prevented?
You probably know that your skin is a natural barrier against infection. Any surgery that causes a break in the skin can lead to an infection, even with the many precautions and protocols in place to prevent one. These are called surgical site infections (SSIs) and begin within 30 days of an incision being made. The most common bacteria that cause SSIs are Staphylococcus, Streptococcus, and Pseudomonas. Germs can infect a surgical wound through various forms of contact, like the touch of a contaminated caregiver or surgical instrument, through the air, or the germs already on or in your body and then spread into the wound. Surgical wounds can be classified in several ways:
- Clean wounds aren’t inflamed or contaminated and don’t involve operating on an internal organ.
- Clean-contaminated wounds have no evidence of infection at the time of surgery but do involve operating on an internal organ.
- Contaminated wounds involve operating on an internal organ with a spilling of contents from the organ into the wound.
- Dirty wounds are those in which a known infection is present at the time of the surgery.
The Centers for Disease Control and Prevention (CDC) states there are three types of surgical site infections.
- Superficial incisional SSI is when the infection occurs just in the skin where the incision was made.
- Deep incisional SSI is when the infection spreads beneath the incision area into the muscle and the tissues surrounding it. This type might result if a Superficial SSI isn’t treated or you have a medical device implanted.
- Organ or space SSI is when the infection can be in any body area other than skin, muscle, and surrounding tissue involved in the surgery.
Symptoms of an SSI can appear within hours to weeks after surgery and include redness, delayed healing, fever, pain, tenderness, warmth, swelling, fatigue, and the formation of pus. An abscess is when pus is enclosed in an area and disintegrates tissue surrounded by inflammation. Samples of the pus can be grown in a culture to find out the types of germs that are causing the infection. Implants can become infected at any time after the operation.
Certain things can increase your chances of having SSIs. These can include having surgery that lasts more than 2 hours, having other medical problems/diseases, being an elderly adult, being overweight, being a smoker, having cancer, having a weak immune system, having diabetes, having emergency surgery, having abdominal surgery, taking certain medicines (ex. steroids), and having poor nutrition. In severe cases, SSIs can cause complications, like sepsis (an infection in your blood that can result in organ failure). Rates of infection differ depending on the type of surgery. The chances of developing an SSI are about 1% to 3%, with estimates of 500,000 them occurring every year in the United States.
Most of the time, SSIs are treated with antibiotics (the type depends on the bacteria causing the infection). However, additional surgery or procedures may be required to reopen and clean the area. Sometimes, deep wounds need to be packed with gauze that is changed often until the wound starts to heal from the inside out. If an infection occurs where an implant is placed, the implant may be removed. Your healthcare provider will figure out what needs to be done to treat your surgical site infection.
The CDC provides regularly updated recommendations for doctors and hospitals to help prevent SSIs. This involves having all hospital staff clean their hands and arms up to their elbows with an antiseptic agent just before the surgery. In addition, hospital staff needs to wash their hands with soap and water or an alcohol-based hand rub before and after caring for each patient. Any staff in the operating room must wear special hair covers, masks, gowns, and gloves. The operating room has special air filters and positive-pressure airflow to prevent unfiltered air from entering the room.
The surgical area is cleaned with special antiseptic soap, and any hair is usually removed with electric clippers before surgery. When indicated, you’ll be given antibiotics before your surgery starts. This typically occurs within 60 minutes before the surgery begins. The antibiotics should be stopped within 24 hours after surgery. This helps kill germs but prevents problems that can happen when antibiotics are taken longer.
It’s also vital to control blood sugar levels during surgery because the stress of surgery can cause them to rise. High blood sugar delays wound healing and increase the chances of infection. Another essential element is a lower-than-normal temperature during or after surgery because it prevents oxygen from reaching the wound and makes it harder for your body to fight infection. Part of avoiding infection is wound care. After surgery, a closed wound is covered with a sterile dressing for a day or two. Open wounds are packed with sterile gauze and covered with a sterile dressing.
If you are having surgery, ask your doctor what you can do to reduce your risk of an SSI. One of the things they’ll recommend is that you stop smoking (if you do). They’ll also want you to wash with an antiseptic cleanser and avoid shaving the area because it could result in minor cuts that bacteria can enter your body. If you do not see your providers clean their hands, please ask them to do so. After surgery, carefully follow your doctor’s instructions about wound care. Always wash your hands before and after caring for it. Don’t allow loved ones to touch your wound or surgical site. In addition, they should clean their hands with soap and water or an alcohol-based hand rub before and after visiting you. If prescribed, take preventive antibiotics. Also, eat healthy foods that promote healing. Make sure you know who to contact if you have questions or problems after you get home.
A common thing people fear when having surgery is having it completed on the wrong body part, undergoing the incorrect procedure, or having a procedure intended for another patient. These are known as wrong-site, wrong-procedure, and wrong-patient errors (WSPEs). They’re called never events by the National Quality Forum, meaning that they should never occur and indicate serious underlying safety problems. The Joint Commission refers to them as sentinel events. As of February 2009, the Centers for Medicare and Medicaid Services (CMS) announced that they would not reimburse hospitals for any costs associated with WSPEs.
How common are these events?
According to a seminal study, these errors occur in approximately 1 of 112,000 surgical procedures. Essentially, it’s infrequent enough that an individual hospital would only experience one such error every 5–10 years. It’s important to note that this estimate only includes procedures performed in the operating room. It doesn’t consider procedures performed in other settings (ex. ambulatory surgery or interventional radiology).
According to a 2020 report from medical liability insurer Coverys, surgery is the second most common cause of medical malpractice claims against doctors overall. The insurer analyzed five years of closed medical malpractice claims from 2014 to 2018. Three types of surgery made up nearly 50% of surgery-related claims, which were general surgery (22%), orthopedic surgery (17%), and neurosurgery (8%). Around 29% of the injuries were considered “permanent significant” or worse, and 9% resulted in patient deaths.
The analysis discovered that surgery-related claims accounted for 25% of the cases, with 78% of those related to practitioner performance during the surgery itself. Other problems were leaving a foreign body (7%), performing an unnecessary procedure (4%), wrong side/site/patient (3%), and a delay in surgery (3%). Unfortunately, 62% of the surgeons responsible for never events were involved in more than one incident.
What’s even more concerning is that the actual number of surgical mistakes is likely even higher because many never events go unreported. This is because hospitals are only required to report never events that result in a settlement or judgment. Also, not all items left behind after surgery are discovered.
Root cause analyses of WSPEs reveal communication issues as a prominent underlying factor as to why they occur. Another issue is incompetence, meaning the surgeon isn’t adequately trained or not trained to handle the specific operation involved. If a doctor is tired from being overworked, errors are more likely to happen. There’s a surprising number of doctors under the influence of alcohol or drugs when they perform procedures. When it comes to staffing, sometimes there isn’t enough support staff.
Some other contributing factors to sentinel events are OR booking documents aren’t verified by office schedulers, time constraints during patient verification that cause staff to rush, ineffective hand-off communications or briefing processes, site mark(s) are removed during prep or covered by surgical draping, the surgical time out is performed without full participation, senior leadership is not actively engaged, and there is an inconsistent organizational focus on patient safety.
Early efforts to prevent WSPEs concentrated on developing redundant mechanisms for identifying the correct site, procedure, and patient. One such initiative was “sign your site,” which instructed surgeons to mark the operative site. However, it soon became apparent that even this seemingly simple intervention was problematic because there was confusion over whether the marked site indicated the area to be operated on or the area to be avoided. Despite this, site marking remains a core component of The Joint Commission’s Universal Protocol to prevent WSPEs.
Another concept is the surgical timeout, a planned pause before beginning a procedure to review essential aspects, such as the patient’s name and procedure, with all involved personnel. It was developed to improve communication in the operating room and prevent WSPEs. The Universal Protocol also specifies the use of a timeout before all procedures.
Part of communication involves counting sponges and other equipment before and after surgery. This is usually part of a surgical checklist, one of several that are used. These checklists have improved surgical and postoperative safety. The Association of periOperative Registered Nurses (AORN) has created a comprehensive surgical checklist that includes specific steps to be followed at four key surgical phases: pre-procedure check-in, sign-in, timeout, and sign-out. The checklist can be downloaded at www.aorn.org/surgicalchecklist.
The World Health Organization’s (WHO) Safe Surgery Checklist recommends using briefings and debriefings. Debriefings are used at the end of the surgical case to assess how the team performed, what went well, and what areas need to be improved for the next time. One tool healthcare organizations can use is the Safe Surgery Targeted Solutions Tool (TST). This application provides a step-by-step process to accurately measure their performance, identify barriers to excellent performance, and direct organizations to proven solutions customized to address their particular barriers.
An added step most OR staff are doing is team training simulations. This includes all staff members, including anesthesia, and promotes a culture of safety with respect and accountability among all team members. This is incredibly important, so staff feels comfortable reporting a near miss or error. To be effective, it requires leadership members to allocate resources and provide incentives or rewards for promoting the culture of safety.
The other part of creating the right environment is making sure it’s distraction-free. This involves limiting conversations, turning off cell phone ringers, not playing music, and banning visitors/observers while the procedure is taking place. Many hospital operating rooms are adopting the “sterile cockpit” concept used in aviation, which prohibits crew members from performing non-essential duties or activities during high-risk activities, like takeoff and landing.
One thing many agencies suggest is reporting never events to the public. Not only will patients have more information about where to go for surgery, but it’ll also put pressure on hospitals to maintain their quality of care. To make the information uniform, a new standardized system of reporting surgical mistakes is needed.
It’s essential to point out that even with these precautions in place, infections and mistakes still happen. Doctors and hospitals are working to bring down both of these rates. Ultimately, preventing them depends on the combination of system solutions, strong teamwork, a culture of safety, and individual vigilance.