Surgical misadventure: The production and mitigation of serious complications in surgery

Abstract

This research draws on the Normal Accident Theory literature and on a variety of sociological “shop floor” studies from medicine, aviation, and other high-risk domains to critique and reformulate current views of how adverse events are produced in health care settings. Organizational error is both a category of deviance that is central to the maintenance of professional identity, and a reflection of the maturational and diffusional processes that characterize the growth of high technology. An increasing societal concern with safety stems from the growing complexity, potency, and invisibility of many new technological systems. We must pay attention to the requirements for organizational and individual learning that accompany the growth of technology if we are to control its potential for danger. In the medical context, this translates to a concern with how to impart experience with disease processes and treatment technologies to individuals, cohorts, and social networks of medical practitioners. Statistical models are used to examine adverse events among adult surgical patients at acute-care Pennsylvania hospitals from 1997–1999. Hierarchical nonlinear (multilevel) models are used to predict accidental injury errors, major complications, and death among patients with complications (“failure-to-rescue”). The models incorporate patient-level predictors and hospital fixed effects for risk adjustment. Variation in risk-adjusted patient-level outcomes is then predicted using surgeon-level variables, including measures of experience, case mix, and surgeon-hospital integration. These models provide mixed support for the hypotheses examined. Surgeon specialty certification has inconsistent estimated effects on adverse events, depending upon the outcome examined. More consistent effects are found for various surgeon practice characteristics, including total surgical volume, case specialization, and average admission severity of illness. In general, surgeons who perform more procedures, surgeons whose case loads are more specialized, and surgeons whose patients exhibit a higher level of illness severity tend have better outcomes, net of the characteristics of individual patients. Poor surgeon-hospital integration predicts some adverse events. Physician-specific effects appear to be more important in the prevention of major complications than in the prevention of death once a complication has occurred