Lessons in Heart surgery!!!

August, 2021

Dear Friends

Last issue I carried the inspiring story that I heard first hand from a Kargil war hero, Capt Naveen Nagappa. This time I want to share lessons from a talk that I heard from another type of war hero – a cardiac surgeon who likens a surgery to a war field, given that in both cases there is zero tolerance to errors. After all it is literally a ‘life and death’ question.
I heard the renowned heart surgeon Dr. Vivek Jawali speak on “Lessons in heart surgery – Zero errors in management”. These were practical lessons from a ‘little-giant’ (a person of petite stature but a towering personality) who has 30,000+ surgeries to his credit. Sharing a few snippets …..

  • Flight, Cardiac Surgery & War – all have variables though flight is predictable. Cardiac surgery & War can be fluid and challenging.

  • Best practice – zero error and open mind.

  • Although individuals may make mistakes, it is possible for teams to be flawless – Teamwork.

  • Humans cannot be punished for systemic errors – create a culture of fearless error reporting (role of whistle blower)

  • How zero error is ensured in pre-operative stage – diagnosis & layers of counter-checks before admission, fast track tests, cross-discipline consultations, pre-procedural plans, check listing, quick calls, multiple cross checks by all team members (sounds like a corporate project preparation, right ?)

  • What are the reasons for error in Operation theatre / ICU – Lack of adequate training, absence of standard rules, major gap in communication between surgeon and others, use of unreliable systems, rush to complete cases due to bad time management – ANSWER to all these maladies is EDUCATION, CHECKLIST, COMMUNICATION (corporate or cardiac surgery lessons ?!!)

  • Errors in other areas – general diagnostic, medication, device & equipment, hospital acquired infections, electronic health records, communication, handing over patient, during acute intervention – all of these can be prevented through SOPs, communication protocol & solid team (it is nothing short of a war room !)

  • Politeness in communication is a NO-NO in a surgery room – could be fatal for the patient at times

Mantras for safety promotion & zero errors

  • Build better teams

  • Build safeguards

  • Be conscious of similar sounding people names in OT (could be disastrous)

  • Reduce time to report abnormal test results (use phone, whatsapp)

  • Give time-out or quiet zone to the nurse

  • Ensure team members accept inherent issues in their roles

  • No room for ego when errors are reported

  • Hierarchy to be rigid and respected

  • Prioritise, expect the unexpected

  • Create a fair and fearless environment for whistleblowing / error reporting

Develop thorough checklists | Foster a solid team | Encourage clear communication |

It was mind-blowing to listen to this management talk from a world renowned cardiac surgeon – so many takeaways and tips that each one of us can adopt for Zero Errors.

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