Blunders During Cardiac Surgery

According to 2019 research, nearly 4.5 lakhs of patients undergo an angioplasty procedure every year. An estimation of around 4 to 4.5 million cardiac surgeries is performed in India. This field is proliferating but also faces backlash from many about its complexity. The complexity of cardiac surgery and the patient's acuity increases the risk of medical errors. ⁽¹⁾ Many research papers have tried to estimate the cause of the high mortality rate faced during cardiac surgeries. The blunders during cardiac surgeries are essentially the genesis of adverse outcomes. Here are a few mentions shortlisted from different research papers:

1. Teamwork

The cardiac surgical operating room consists of highly trained and skilled subspecialties. They mainly include surgeons, cardiac anesthetics, perfusionists, scrub nurses, and other operation theater technicians. Nonetheless, these highly skilled subspecialties are humans and prone to make errors. Many scientific data focus on communication errors. The failure to communicate efficiently is prone to cause errors. The Joint Commission between 2004 to 2012 stated that communication failure was the root cause for 65% of major events which was the contributor to errors in medications, wrong-site procedures, and operative and postoperative events. ⁽²⁾ Another study signified that 89% of errors were due to frequent teamwork failure. ⁽³⁾

2. Cardiac Anaesthesia

Almost every surgery requires anaesthetic intervention, there is an associated risk. According to the American Society of Anaesthesiologists Grade 1 patient, the risk in healthy patients of anesthesia-linked complications is approximately one in every 250,000 patients. ⁽⁴⁾ The analysis by Gild shows that the incidence of equipment-related errors in cardiac anesthesia was higher than in the non-cardiac group. ⁽⁵⁾ This study concludes that reasonable interference in the care of intravenous catheters and cardiopulmonary bypass equipment can reduce the overall risk. The role of anesthetists is pivotal and therefore inaccuracy can happen from induction to shifting the patient back into the ICU. To eliminate this problem, the Society of Cardiovascular Anesthesia (SCA) and the Society for Healthcare Epidemiology of America), and organizations like the World Health Organization are working in alliance.

3. Cardiopulmonary Bypass (CPB)

The use of Cardiopulmonary Bypass is a routine part of cardiac surgery. It is used in almost every surgery and hence increasing the incidence of risk. The cardiopulmonary bypass is run by a Perfusionist. The margin of error during CPB must be very thin, but the machine is liable to blunders. The blunder may vary from an excessive injection of KCl in cardioplegia, air entry in the arterial line, hypoperfusion, etc. Therefore, training and conduct are considered very vital in cardiac surgeries.

4. Surgical Mishaps

The surgeons are famously referred to as the captain, giving operation theater the analogy of a ship. They remain accountable for medico legal matters and hence tend to be disciplinary. The surgical errors vary from sternotomy, rupturing a chamber or major vein or artery, damaging the conduction system, rupturing the valves, etc. The complication can be post-operative leading to death and other complications due to failure of the pumping mechanism. According to the research paper, one-third of avoidable death in low-risk cardiac surgery was related to specific surgical problems. When the data was revisited, 75% of deaths could have been avoided if pre-operative patient evaluation and preparation was done efficiently. ⁽⁶⁾

5. Others

The other factors are broad, comprising errors that are ungovernable. One of the most common blunders is electricity failure, though some machinery has battery backup the tendency of miscalculation can cost a life. Another similar situation is a cut-off in the supply of gases which can cause an alarming situation. Misdiagnosis is usually one the most common phenomenon seen in cardiac OTs leading to the wrong surgery site, more than one dysfunction, incorrect sizing of the structures, etc. There are incidences of retention of surgical instruments from the body, this can't be solely blamed on the surgeon as the scrub nurses are responsible for instrument counts. Machinery failure can include CPB failure, ventilator failure, syringe pump failure, etc. The infection control incidence is common and can be fatal for the patient.

Many associations are collectively working for the betterment of patient safety during cardiac surgery. Many CME and CE are conducted for the training and modification of the practice. The Flawless Operative Cardiovascular Unified Systems (FOCUS) has been introduced to set benchmarks for health professionals. The ultimate goal of cardiac surgery is not only to correct the existing anatomical or physiological errors but also to bring a good quality of life to the patient.

References

1. Elizabeth A. Martinez, Andrew Shore, Cardiac surgery errors: results from the UK National Reporting and Learning System, International Journal for Quality in Health Care, Volume 23, Issue 2, April 2011, Pages 151–158.

2. The Joint Commission. Sentinel Event Data: Root Causes by Event Type. 2011. http://www.jointcommission.org/Sentinel_Event_Statistics/. Accessed May 5, 2013.

3. ElBardissi AW, Wiegmann DA, Henrickson S, Wadhera R, Sundt TM. Identifying methods to improve heart surgery: an operative approach and strategy for implementation on an organizational level.Eur J Cardiothorac Surg. 2008; 34:1027–1033.

4. Sigurd Fasting. Risk in Anesthesia. Tidsskr Nor Laegeforen, 2010 Mar 11;130(5):498-502

5. Gild WM. Risk management in cardiac anesthesia: the ASA Closed Claims Project perspective. J Cardiothorac Vasc Anesth 1994;8:3-6.

6. Omar Asdrúbal Vilca Mejia,corresponding author, Gabrielle Barbosa Borgomoni, Most deaths in low-risk cardiac surgery could be avoidable. Sci Rep. 2021; 11: 1045.

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