Improving diagnostic safety in surgery: A blog by Anna Paisley

Summary

Good outcomes for surgical patients require accurate, timely and well-communicated diagnoses. In this blog, Anna Paisley, a Consultant Upper GI Surgeon, talks about the challenges to safe surgical diagnosis and shares some of the strategies available to mitigate these challenges and aid safer, more timely diagnosis. 

This blog has been published as part of a series for World Patient Safety Day 2024 and the theme of Improving diagnosis for patient safety. #WPSD24, World Patient Safety Day 2024, WPSD 2024.

Content

The surgical journey

Safe diagnosis requires the gathering of information from multiple sources, including clinical history, examination, and laboratory and radiological tests. This information must then be distilled and interpreted to form a working diagnosis for treatment or further investigation. This process is repeated throughout all the stages of surgical care.

Before surgery, an accurate diagnosis of the cause of the patient’s symptoms must be made. As the patient’s comorbidities and frailty are integral to their surgical recovery, these must also be assessed and correctly determined. Ultimately, selection of the correct operation for the patient is only possible if a correct pre-operative diagnosis and assessment has been made.

During surgery, the constantly changing information from surgical findings and from the patient’s response to surgery must be recognised, assessed and promptly processed to direct the ongoing operation and to determine the best course of action. Surgical injury or other complications also need to be recognised, correctly assessed and remedied.

After the surgery, deviation from the expected course of recovery and any sudden deterioration, such as sepsis, must be promptly identified to allow necessary interventions and rescue. Results of tests carried out during surgery, such as pathology from biopsies, must be followed up appropriately to ensure that the definitive diagnosis or stage of disease is properly evaluated.

What are the challenges to safe surgical diagnosis?

At each stage of the surgical journey a number of factors influence the safety of this complex and evolving diagnostic process. These challenges to diagnostic safety can be divided into cognitive, systemic and communication-related factors.

A robust diagnostic process relies not only on the knowledge and training of surgeons but also on cognitive factors, such as bias and limitations in clinical reasoning or failures of perception, which have been linked to up to 80% of diagnostic errors in surgery.[1] The rapid, often split-second, life or limb saving decision-making typical of surgical care is most at risk of such failures of judgement and cognitive bias. The focus is often on initial pieces of evidence or readily available information rather than the more comprehensive analysis, and this can lead to diagnostic errors and omission or error in the patient’s treatment resulting in a poorer outcome.

The system within which surgical care is provided can contribute to unsafe diagnosis. Poor workflow design, time constraints and staff shortages all increase the pressure for rushed, incomplete and limited evaluation of a patient’s condition. Limited access to diagnostic testing, such a radiology, or delays in test results becoming available or being acted on, all increase the risk of missed or incorrect diagnosis.

Communication problems within a team is a common barrier to safe diagnosis. Failure of effective communication between healthcare professionals and with patients leads to misunderstanding about a patient’s condition and test results. Handover from one team to another, which happens frequently during surgical care, risks the loss of vital diagnostic information and potential significant patient harm.

How can we improve surgical diagnostic safety?

There are many strategies available to mitigate these challenges and aid safer, more timely diagnosis. The Royal College of Surgeons of Edinburgh (RCSEd) provides many resources aimed at improving surgical diagnostic safety and other aspects of patient safety.

Training

• Surgical training must include both factual knowledge and technical skills training. Courses focussing on improved clinical reasoning and reducing bias help to enhance diagnostic accuracy. Training programmes such as NOTSS (Non-operative technical skills for surgeons) promote training in human factors to improve patient safety in the operating theatre. In addition, RCSEd's role in setting surgical standards, examinations and the activities of the Faculty of Surgical Trainers ensures that surgical training aims to equip surgeons with the skills required in practice. 

Investment

• Investment in diagnostic pathways and technologies for more accurate, rapid diagnosis, such as the implementation of diagnostic units or hubs, can help to optimise workflows and time pressures while making the most effective and safe use of the available workforce. Diagnostic units are designed to bring multidisciplinary health care professionals, diagnostic testing and some procedures together in the same unit to provide outpatient diagnosis and treatment, making the best use of resources and mix of skills in a ‘one stop’ model of care. These units can be in larger hospitals, community health clinics or stand alone. They also provide an excellent setting for peer support and professional development of the healthcare workforce. Recommended by the Richards report,[2] these units have been developed by programmes such as GIRFT (Getting It Right First Time) in specialties such as urology.

Communication

• Communication is key in all healthcare provision and standardised methods, such as SBAR (Situation, Background, Assessment, Recommendation) , reduce the loss of information at times such as team handover. Human factors training such as NOTSS also improves team-based communication. Shared decision making, as in the ICoNS course, can maximises information exchange between patients and healthcare providers, reducing errors.

Reporting systems and shared learning

• Appreciation of the challenges to safe diagnosis and strategies to mitigate these can only be fully realised with robust reporting systems and shared learning from any errors identified. The RCSEd’s Team-Based Quality Review Workshop provides training in significant event reviews.

In striving for the best outcomes for patients, safe diagnosis is crucial. Errors in diagnosis can have devastating consequences and must be addressed with recognition of the challenges, effective learning from errors and mitigation of the major factors identified.

References

1. Kwan JL, Calder LA, Bowman CL, et al. Characteristics and contributing factors of diagnostic error in surgery: analysis of closed medico-legal cases and complaints in Canada. Can J Surg. 2024 Feb 6;67(1):E58-E65. 
2. Richards M, Maskell G, Halliday K, Allen M. Diagnostics: a major priority for the NHS. Future Healthc J. 2022 Jul;9(2):133-137.

Share your experience

Have you been affected by a late diagnosis? Or perhaps you have insights to share on diagnostic safety through the work that you do. If you would like to write a blog or share your thoughts, experiences or resources through the hub please get in touch with our team at [email protected] or add your comments to our community forum page. 

About the Author

Anna Paisley is a Consultant Upper GI Surgeon, RCSEd Council Member and Patient Safety Group Chair.