Study identifies why child heart operations go wrongBMJ 1999; 319 doi: https://doi.org/10.1136/bmj.319.7213.803 (Published 25 September 1999) Cite this as: BMJ 1999;319:803
Human and organisational factors have a significant role in determining whether a surgical operation has a good or bad outcome, according to research outlined last week to the public inquiry into child heart surgery at Bristol.
Marc de Leval, professor of cardiothoracic surgery at Great Ormond Street children's hospital in London, previewed the results of a study which looked at all the arterial switch operations performed in the United Kingdom over an 18 month period. Of 230 operations, 165 were studied in detail. The research is to be published soon in the Journal of Cardiothoracic Surgery.
The switch, performed in the first month of life to correct transposition of the great arteries of the heart, is one of two paediatric heart operations looked into by the General Medical Council in its long running investigation into the Bristol case last year.
The GMC found two surgeons guilty of serious professional misconduct for continuing to operate after concerns were raised about mortality and morbidity. The former chief executive of the United Bristol Healthcare Trust was also found guilty for failing to intervene.
The public inquiry heard that the switch research was modelled on studies of human factors in “near misses” in aviation. Death after surgery was equated with a crash, and near misses with cases where the patient needed mechanical support after the operation or where there were serious complications such as lasting neurological problems or deep seated infection.
The study found a mortality of 6.5% and an 18.5% incidence of near misses Funded by the British Heart Foundation, it looked at a range of factors including personnel availability, bed space in the intensive care unit, distractions and interruptions during the operation, equipment design and reliability, monitoring of displays or equipment, and preoperative briefing of the team. A researcher was present in the theatre for almost all the operations.
Professor de Leval said the distribution of the coronary arteries was a key factor in determining how risky an operation was. The intramural coronary artery, where one of the arteries was partly inside the wall of the aorta, carried the highest risk.
Institutional and organisational problems also played an important part in determining outcome, particularly in higher risk cases. Events such as problems with availability of beds, difficulties in coordination with the blood bank, inappropriate delegation of tasks, equipment problems, incorrect readings of electrocardiograms, and positioning and tensioning errors by surgical assistants increased the risk of death or near miss.
But these events, including the distribution of the coronary arteries, could often be compensated for. “The study shows that a good compensation will provide a good outcome, even with difficult coronary arteries.”Errors were inevitable, he said. “What we have to do is build systems which are error tolerant.”
The study did not follow the patient beyond the point at which he or she was handed over to the intensive care unit, but further research is looking at this area.
• Sir Donald Irvine, president of the GMC, told the inquiry that the council had consulted extensively with NHS employers to make it as clear and explicit as possible that any default from the standards of good medical practice should automatically trigger a complaint to the GMC, if employers could not handle it themselves.
“Huge numbers” of chairmen and chief executives had been quite unaware of that fact. Sir Donald said the GMC had power to act only as a result of a complaint, but it did scanthe press and there was nothing to stop it inquiring whether someone wanted to make a complaint.