Aortic aneurysm screening: a personal history

Correspondence to: Haogeng Sun (email: s666888sci@163.com)

37 Guoxuexiang Street, Chengdu

Tel: 028-85423489

Despite an increasing emphasis on patient safety, modern surgical practice is still plagued by the occurrence of serious Adverse Events (AEs). A large proportion of these AEs are caused not by technical errors, but short comings in non-technical skills (NTS) or non-technical errors.1 NTS are the cognitive and interpersonal components of surgical professionalism including communication, decision-making, situational awareness and leadership.2 Few studies have attempted to quantify the significance of non-technical errors leading to patient harm. Those that have, only include small, non-representative cohorts, or have assessed for NTS shortcomings using heterogeneous, non-standardised, and non-comprehensive assessment methods.3-6 As a result, the true impact of non-technical errors, and information about how, when, and why these errors occur are poorly understood. Evidence to guide NTS improvement is lacking.

This study7 aimed to investigate the incidence of non-technical errors linked to patient death in a large representative Australian cohort, investigate factors associated with fatal non-technical errors, and whether the incidence of non-technical errors had changed over time. To achieve this, an 8-year retrospective audit using surgical mortality cases was conducted. Data were derived from the Australian and New Zealand Audit of Surgical Mortality (ANZASM) a mandatory, national surgical mortality audit overseen by the Royal Australasian College of Surgeons. In Australia, every surgical death is reported to ANZASM for external peer review for the purpose of identifying clinical management issues (CMI’s) that could be improved in future. CMI’s are rated on a three-tiered system with ‘area of concern’ or ‘Adverse Event’ representing the two most serious. All surgical deaths between 2012-2019 (excluding New South Wales), flagged with an area of concern or AE were included with no further exclusions. Each case was assessed using the System for Identification and Categorization of Non-technical Errors in Surgical Settings (SICNESS), a validated tool, developed by the study authors.8 The SICNESS enabled assessors to identify if a non-technical error linked to patient death had occurred, and if so, to which NTS domain it belonged.

There were 30,971 surgical deaths reported to ANZASM during the study. Of these, 3829 were flagged with an AE or Area of concern. Some 134 had insufficient information for assessment, leaving 3695 cases for review. A non-technical error linked to patient death was identified in 2354 cases (63.7%). Of the cases with non-technical errors, 1375 (58.4%) had decision making errors, 1328 (56.4%) had situational awareness errors, 357 (15.2%) had communication/teamwork errors, and 128 (5.44%) had leadership errors.

In a recently published cross-sectional study in BJS1, Dr Marianna Kapestaki examines diversity amongst paediatric consultant surgeons in the UK. It comes as no surprise that the majority of consultants and full professors were men, whilst 73.5% of consultants were white. On the bright side, no gender or racial disparities were found in other academic parameters such as being affiliated with a university or having earned a PhD. Dr Kapestaki presents several other parameters in her study which may or may not be significantly associated with gender, racial or academic inequalities. She goes on to state that the findings in paediatric surgery are consistent with those in neurosurgery and neurology in the UK.

A study like this is important for several reasons. First, it sheds light on the importance of dissecting the surgical workforce for potential inequalities and possible discrimination, including highly subspecialized branches of surgery such as paediatric surgery. Second, it demonstrates that lack of diversity at consultant level is a persisting problem, but one that is definitely remediable once sufficient awareness of the issue is established. Finally, it seems fair to infer from the findings that the solution may lie in the problem itself, namely academia. If there are indeed no disparities in academic achievements such as completing a PhD or becoming affiliated with a university, then with sufficient awareness and deliberation, these same individuals should conscientiously be chosen to higher positions of consultant and full professorship. One can only hope.