SURGICAL MASTERSCRIPTS: All the What to do’s, How to do it’s, What if’s, checks and checklists, plus error prevention, avoidance, and correction.
Michael Edwards FRCS and Riaz Agha MRCS MB BS (Hons), editors of Wikisurgery.com, London.
Unlike aviation, surgery is not a high reliability industry. Of 4 million operations per year in England, surgical errors leading to death (300+) or serious injury (1300+) is comparable with five or more airliner crashes 1.
Lack of experience has been sited as contributing to over half of such errors 2. There is, in fact, a serious lack of available expert operative information in surgery. A major operation lasting 4 hours or more may be described in an operative surgical textbook in 7 pages or less, or in a 20 minute video 3, 4. Trainee surgeons in the UK have had their learning time in the operating theatre reduced by up to 80% by the European Work Time Directive 5.
One approach to improve the situation is to create scripts with all the information that a surgeon uses before, during and after the operation. This involves a change from the view that, for instance, all the important information should be contained on one sheet of A4 paper. Using a website, there is no limit to the amount of information that can be documented on these scripts. Wikisurgery.com is the only source of such scripts, each containing over ten times the amount of information in an operative textbook or in a How I do it article 3,6,7,8.
The scripts contain the WHO safety checklists, which are applied before and after the operations. They also include information about how to perform these checklists correctly. The operations themselves are described in an unlimited number of steps (ie what to do). About 10% of the steps are checks that a surgeon performs as part of the normal procedure. Each step contains unlimited backup information (ie How to do it, with all the what if’s, plus error prevention, avoidance and correction).
The scripts can be modified to suit any expert surgeon’s preferences.
These scripts are complementary to the non-technical aspects of surgery which have been extensively studied.
They are very similar to pilots’ Standard Operating Procedures used in their safety manuals.
The scripts could form a key to moving surgery towards the high reliability achieved in aviation.
Plans are underway to pilot these scripts. If they prove to be beneficial, they could be promoted widely to reduce errors and improve surgical training.
1 Catchpole K et al. 2009, National Patients Safety Service, National Reporting and Learning Service.
2 Gawande A et al. Analysis of errors reported by surgeons at three teaching hospitals. Surgery 2003; 133: 614-621.
3 Arko F, Smith S, Zarins C. Repair of infrarenal abdominal aortic aneurysms. In: Souba W, Fink M, Jurkovich G, editors. American College of Surgeons ACS Surgery Principles and Practice. 6th ed. New York: Webmed MD; 2007. p 1107-1112.8.
4 Leroy J Anterior resection with TME for T2 cancer of the upper rectum in a female patient. http://www.websurg.com/video/index.php?doi=vd01en2074&redim=1> 14 August, 2012
5 Glomsaker T, Søreide K. Surgical training and working time restriction. Br J Surg 2009; 96:329-330.
6 Edwards M H and Agha R. WikiSurgery.com [http://www.wikisurgery.com/index.php?title=Main_Page> 14 August, 2012
7 Edwards M and Knox R. 2012 Aortic aneurysm graft [http://www.wikisurgery.com/index.php?title=Aortic-aneurysm-graft-Operationscript> 14 August, 2012
8. Macaulay E, Engeset J. How I do it: Abdominal aortic aneurysms. Surgeon 2000; 45:171-177.