Things go wrong in the operating room; that’s no secret. If reports are correct, there are more than 4,000 surgical “never events” per year in the United States.1 Fortunately for our patients, most experienced surgeons anticipate such obstacles and both patients and surgeon usually survive unscathed. When things go wrong in the OR, it is imperative that we are adequately prepared to handle unexpected challenges and still provide exceptional surgical care.
The Institute of Medicine’s report, “To Err is Human,” sparked a national outcry for safer medicine. Surgical checklists and ACGME-mandated reduced-hour work regulations have been instituted to reduce the effects of human error on patient outcome; the results of the latter have been mixed.2 We borrow heavily from aviation standards whose protocols attempt to diminish the impact of human mistakes; nevertheless, a hospital is complex machinery whose parts are imperfect humans. Weekly quality improvement (QI) conferences held across U.S. academic surgery departments highlight the fact that complications still occur with some regularity. Some of these morbidities are related to patient disease while others can be attributed to error in judgment and technique. Perhaps the most important variable separating potentially catastrophic outcomes versus tolerable morbidity is whether surgeons employ sound and calm judgment in the face of adversity.
Throughout surgical training, and as evidenced by inclusion in new residency training milestones, intraoperative surgical decision making is stressed as a hallmark of a facile and safe surgeon. Despite general consensus that judgment in the OR is important, the literature evaluating this relatively amorphous and subjective concept is scant. A very eloquently written article on the subject of naturalistic decision making and situational assessment necessitates direct quoting:3
Researchers involved in naturalistic decision making strive to describe how experts make decisions in conditions of high uncertainty, inadequate information, shifting goals, high time pressures and risk, usually working in teams and subject to organisational constraints.
It renders credence to the concept that we do not often have the luxury of a perfect solution intraoperatively; rather, the goal is to achieve a safe outcome in the face of rapid decompensation or unexpected obstacles.
The combination of a high-stress and high-stakes operation can lead to extremely emotional responses to intraoperative difficulties, both from the surgeon and the nurses. A 2008 New York Times article “Arrogant, Abusive and Disruptive—and a Doctor” illustrates the much feared scenario where a patient suffered because the surgeon did not listen to the nurse. To be sure, it happens. Pronovost, a patient safety guru, noted that arrogance and the culture of fear leads to poor patient outcomes.4 For the vast majority of surgeons who don’t throw instruments or scream at nurses, the message is age-old—“don’t be arrogant.” Recognize that errors can happen ...