Why Organize the Safety in Spine Surgery Summit?
One of the questions I often received prior to the first annual spine safety summit in 2016 is “why organize another Spine Surgery conference?” My answer is inevitably, “how could we not?”
The time could not be more urgent. At every talk I give, I always like to put the audience in the right mindset, which is “how will the next patient be harmed?” Somewhere out there, there’s a patient coming to your waiting room or in a cab or on a plane that may be harmed. The question isn’t if, but when.
In reality, no one is safe, the patient or the surgeon, including the emotional toll that comes from potentially harming a patient.
As a field, we are not doing well. Even if we pride ourselves with 99.9% positive outcomes, we are still left in the dust by others who are doing better. As a framing picture, we would find this unacceptable if:
- Amazon failed to deliver 1,600 parcels each day
- USPS lost 506,000 pieces of mail each day
- 1,019 surgeries went wrong every month
We always need to ask ourselves, how far would you be willing to go to avoid harm? Often times, the answer isn’t from punishing physicians and nurses. It’s not an issue of bad physicians or nurses harming patients, but a poor system setting up good physicians and nurses that eventually harms patients. Even the most technically skilled and fantastic of surgeons can’t do a great job, unless they have the infrastructure to support them and a team surrounding them with good communication. More and more, with lessons from high reliability organizations such as aviation and nuclear power as well as from the peer-reviewed literature, we are learning that over focusing on the concepts of individual skills undervalues the reality that care is a result of the entire episode of care, requiring a systematic approach to managing everything within the realm of influence, from preoperative access to recovery and rehabilitation.
Just like Jim Reason’s timeless model, the Swiss Cheese Model of Medical Error, if we think about all of the elements of risk, host, technique, systems, and culture, then we realize that medical error and complications occur only when all of the holes line up just right.
As we start this blog, I am hopeful that the Safety in Spine Surgery Project (S3P) will evolve into a platform where we can engage the wisdom of the entire industry to shrink the critical holes that too often lead to poor outcomes for our patients:
- Lack of Infrastructure
- Individual Thinking & Decision Making
- Lack of Information in a Data Rich System
- Poor Culture
S3P will provide an infrastructure and platform in which we can work together to tackle some of these issues throughout spine surgery and hopefully implement strategies across the board. But we need participation and buy in at ever level, from industry partners, hospitals, peers and colleagues, and each individual physician. Patient safety and quality starts with physicians, but it doesn’t end there.
This is such an exciting time and we would love your feedback on how S3P can take quality in spine surgery to the next level. In future blog posts, we’ll talk more about some of the frameworks for change we envision and the efforts that have evolved as a result. We look forward to hearing from you.