Surgeons can’t be responsible for every mistake

Several months ago, a post called, “Everything’s my fault: How a surgeon says I’m sorry,” appeared here on KevinMD.com. It was written by a plastic surgeon who feels that no matter goes wrong with a patient, surgeons should never blame anyone else.

She gave some examples such as the lab losing a specimen, a chest x-ray that was ordered and not done, a patient eating something when he was not to be fed, and a surgeon having to cancel a case because the patient’s blood pressure was elevated. She felt that all of these incidents should be owned by the patient’s surgeon.

I agree that if I order a chest x-ray and find out later it wasn’t done, I would accept the responsibility to have made sure it was done. I have always believed that you should not order a test if you aren’t going to do something with the result.

But if the lab loses a specimen or a patient who was not supposed to eat does so, how is that my fault?

Yes, it is very noble to stand up at a morbidity and mortality conference and say, “Everything is my responsibility.” It’s also good roundsmanship because it cuts off further criticism. No one can heap further abuse upon the doctor if she has already admitted fault and accepted responsibility?

But accepting the blame implies that you are going to do something to prevent the error from occurring again.

How does a surgeon prevent a food service worker from putting a tray of food in front of a patient who is NPO? Believe it or not, I used to tell every patient I operated on, “Don’t eat anything after midnight, even if someone brings you food.” Do you think that always worked? The answer is, “no.”

The example of a case being canceled because of an elevated BP is a good example of why a surgeon saying everything is his fault is misguided. At an morbidity and mortality conference described in the post, this exchange was said to have occurred:

“It’s your responsibility to know the blood pressure in advance,” a senior surgeon called out from the back of the room.

“Of course,” the young surgeon said, with complete sincerity. “Everything is my responsibility.”

And just how did the young surgeon plan to prevent a patient’s BP from going up prior to surgery? It is common for patients to become anxious before an operation, occasionally leading to hypertension. Should she stay at the patient’s bedside overnight? Should she put every preop patient in an ICU? How does one stop that sort of event from happening?

Here are some possible scenarios. You tell me if the surgeon should say, “It was my fault. I’m sorry.” If you think it is the surgeon’s fault, tell me how a surgeon can prevent its recurrence.

  • A nurse gives a surgeon’s patient a medication meant for another patient.
  • After a CT scan, a patient falls off the gantry in the radiology department.
  • While drawing routine lab work, a phlebotomist injures a patient’s brachial artery.
  • Without warning or a previous history of mental illness, a patient jumps out a window.

I don’t see why in the 21st century, when medicine is a supposed team sport, one person should assume responsibility for everything that happens to a patient.

“Skeptical Scalpel” is a surgeon blogs at his self-titled site, Skeptical Scalpel.

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  • Patient Kit

    Slightly off topic, but I’m amazed that patients are in the hospital the night before surgery where they might be served a tray of food. For my last 3 surgeries (two of which were fairly serious — OVCA and Achilles tendon hanging on by a thread), I had to report to the hospital around 5:30am in the morning to be prepped for surgery. My only other surgery was an emergency (pathologic femur fracture) in which I was admitted via the ER for surgery that was done later that same day. I was never admitted the day before surgery. But being the responsible patient that I am, I never ate or drank after midnight the day before surgery because I hate the idea of vomiting while anesthetized and intubated. I think if patients really understand WHY they shouldn’t eat before surgery, they would remember not to eat before surgery. But, if I did disregard instructions and eat before surgery, I would not blame my surgeon.

    • Skeptical Scalpel

      Many patients are admitted as emergencies, worked up, and taken to surgery during the same admission. We also get consults on patients who have been admitted to other services and then go to the OR.

      • Patient Kit

        That, of course, makes sense. I guess I’m so used to so much surgery being done on an outpatient/ambulatory basis now, even fairly serious surgery, that I forget that some patients are actually admitted to the hospital before having surgery. I usually find it difficult to get any sleep the night before surgery because I’m afraid I’ll oversleep and not get to the hospital by 5am. So, it’s usually no sleep for me the night before surgery. But I also don’t eat.

  • J Rizzo

    In regards to those specific examples- you are right- it is a a team sport. But frankly these examples are a red herring argument and really extreme examples of issues that are not a surgeon’s responsibility. What patients and your colleagues want you to be accountable for is the quality of the surgery, the level of care pt’s receive post op continuing through therapy and education afterwards, and for surgeons to acknowledge and care if a surgery they do offers has predictably little to no benefit for the patient (despite it being profitable). It would also be nice if more surgeon’s took accountability for the opiate addicts they create, specifically orthopods.

  • Thomas D Guastavino

    Question 1: What are the consequences for taking that responsibility? Sorry, I am will not risk having my license revoked because of someones else’s mistake.
    Question 2: Do we really want to risk seeing another toxic tort commercial saying “Did your surgeon sit by and do nothing while you ate the meal served to you before surgery, even if you were told not to ?. Call 1-800-BAD-DOCT”
    I think Ill only own up to my own mistakes, thank you.

    • Patient Kit

      That seems totally fair and reasonable to me. We all have to take some personal responsibility, both docs and patients. There are way too many people out there who — when I say that people should not jump off a boat into the ocean if they don’t know how to swim, ask me with true wonderment, why not? And then, if they drown, their family wants to sue someone. Not exactly the same thing as patients eating before surgery when they were told not to, I know. But still. Even annoying liberals like me can believe in personal responsibility. ;-)

  • Eric Strong

    When a doctor accepts responsibility for something that was beyond his/her control, it limits the ability of the hospital to identify and correct the actual cause of the problem. (e.g. making sure all patients who are NPO have signs stating such on their doors and/or above their beds, training the food service workers to look for these signs, and holding someone accountable when a sign is either missing or was disregarded.)

  • Suzi Q 38

    Just because there is a bad outcome, it doesn’t mean that it is all the surgeon’s fault. There could be a number of reasons, seen and unforeseen that could happen during and after the course of a surgery.
    I try to avoid surgeries, as I realize that so much can happen. I don’t care how “routine” and simple the surgery is considered, stuff happens.

  • Patricia

    Perhaps the important take away here is that a ‘need’ exists that has to do with mistakes and accountability. What is missing is systemic structures that make sure these mistakes don’t happen. It’s odd to think of the doctor or surgeon at the top of a pyramid of control. Patient education is very much lacking (such as patients not knowing *why* they shouldn’t eat before a surgery, as mentioned below). I see the culture of medicine to be very cemented into a certain structure and it should change in order to cut way down on the number of mistakes and harm caused by medical care.