Abstract
Keywords
Surgical procedure is a high risk event, like flying or diving. Most of the time everything goes smoothly and it is very easy to think that nothing bad can happen. Well, it can, and it does. And there is no limit how bad things can go. Minimizing risks with strict safety procedures, manuals, checklists, drills and meticulous reporting and analyzing of near-misses has reduced airplane accidents to a minimal level (but not zero). The last few years have seen the same features been incorporated in medicine and especially surgery. The use of surgical safety checklist, for example, has been shown to reduce mortality and morbidity to almost half in adult noncardiac surgery (1).
In surgery, adverse events (errors or complications) occur in 3.8–17% of hospital admissions, 37–51% is preventable, 7% lead to permanent disability and 7% to death (2). Complications are twice as common as errors. The most common one is an error in technique followed by error in judgement (2). The most common surgical complications are infectious, pulmonary, bleeding, and cardiac complications, respectively (3). The most common postoperative complication after major hepatobiliary or gastrointestinal surgery is anastomotic leak that occurs in 4.5% after elective and in 6.8% after emergency surgery (4). In colorectal surgery anastomotic leaks occur in 2.7–7.9% and in 7.7–17.1% following pancreaticoduodenectomy (5,–7).
Every patient has the right to safe surgery, as safe as possible. Every tax payer has the right to expect that tax money is used wisely. “Complications increase hospital costs and even a small reduction in the number of complications will result in a substantial hospital cost savings and a reduction in the emotional and physical burden of the patients” (8).
The first step in reducing complications is to know how much and what kind of complications do occur in your hospital. Relying on reports at mortality and morbidity conferences, and retrospective analyses of patient cohorts based on hospital records or administrative data is notoriously unreliable. Prospective, systematic and comprehensive collection of complication data of all surgical treatment episodes is the best way. Even then a learning curve can be expected, but a fully automated registration system and patient-centered way of registering complications has been shown to dramatically improve data quality (3).
Almost every major conceptual improvement in science has required a new way to classify and categorize a natural phenomenon. Complications are no different. Some of them are minor, some major, they have different consequences, and they should be separated from surgical sequelae that are inherent in the procedure and occur inevitably (such as a scar) or failure to cure referring to diseases or conditions that remain unchanged after surgery (9). Many classification of complications exist but perhaps the most useful is the Clavien-Dindo classification that has five grades of severity (with grade 5 being patient death) and has been recently updated (10).
To improve quality one has to look at structure, process and outcomes. One essential component of assessing outcomes is accurate information about complications, closely linked to the overall goal that our treatment actually has a positive impact on the patient's health. Preventing complications is essential to safe surgery, safe surgery is essential to quality. Today is as good day as any to start. Good luck!