Intended for healthcare professionals


Senior surgeon suspended for failing to spot indicators of severity

BMJ 2016; 355 doi: (Published 01 November 2016) Cite this as: BMJ 2016;355:i5902

Re: Senior surgeon suspended for failing to spot indicators of severity

We read Dyer’s article with interest and would like to discuss further with regards to the lack of non-technical skills that has been evident in all five cases that involved this particular senior surgeon.

The current surgical training in the United Kingdom is based on the principle of competency-based assessment. This has allowed an increased emphasis on developing surgeons who understand and recognise the safest and most effective management of patients.[1] This change in the direction of surgical training encourages the awareness of the importance of human factors and non-technical skills of surgeons (NOTSS) which are defined simply as the interaction between humans and the systems by focusing on improving efficiency, creativity and productivity with goal to minimise error. [2]

In this article, we recognised that the senior surgeon, although having many years of experience and undeniable technical skill, demonstrated a lack of crucial non-technical skills such as situation awareness, decision-making, effective communication and leadership. These are perceptive and interpersonal skills that complement a surgeon’s technical flair.[3]

Between 2003 to 2010, a prototype NOTSS system was developed with cognitive task analyses, which corroborated the four broad categories aforementioned, leading to the development of NOTSS taxonomy.[4] This prototype was proven reliable by surgeons and subsequently became an educational system for assessment of surgeon’s behaviours in theatre.[5] Currently, NOTSS is in the process of being integrated into the online Intercollegiate Surgical Curriculum Programme (ISCP) portfolio.

Modern surgical training and practice should be based on the principles of the pursuit of excellence and the promotion of patient safety. Undeniably, there exist human factor limitations that will affect a surgeon’s performance at some point in their career regardless of their seniority, competency or level of experience. The NOTSS system acknowledges these factors affect the performance of surgeons, which include organisational failure, situational difficulties, team quality, and more importantly physical limitations such as fatigue, fasting and memory.

In 1991, Wilson et al performed an analysis into human error in adverse events. It was found that 34.6% of adverse events were attributable to human error. Of which, the most common cause was a failure to decide and/or act on available information (15.8%), followed by failure to request or arrange an investigation/procedure (11.8%), and finally around 10.9% of adverse events were secondary to failure to attend to the patient.[6] It is noted that some of these failures discussed in the research can be seen in this particular senior surgeon.

Society and media are unforgiving of our mistakes – whether this attitude is appropriate or otherwise, as clinicians we have a duty to our patients and should never breach that duty of care as set out by the GMC good medical practice.[7] We believe that developing our non-technical skills and awareness of the influence of human factors in surgical performance would make us more effective and safer surgeons. We therefore look forward to seeing the formal introduction of NOTSS into the surgical curriculum in the United Kingdom.

1. Yule S, Fling R, Maran N, Youngson G, Mitchell A, Rowley D, et al. Debriefing surgeons on non-technical skills (NOTSS). Cogn Tech Work. Springer-Verlag; 2008;10(4):265–74. 
2. World Health Organization (WHO). Human factors in patient safety. 2009.
3. Yule S, Flin R, Paterson-Brown S, Maran N. Non-technical skills for surgeons in the operating room: a review of the literature. Surgery. Elsevier; 2006 Feb;139(2):140–9.
4. Yule S, Flin R, Paterson-Brown S, Maran N, Rowley D. Development of a rating system for surgeons' non-technical skills. Medical Education. Blackwell Publishing Ltd; 2006 Nov;40(11):1098–104. 
5. Yule S, Flin R, Paterson-Brown S, Maran N, Rowley D. Surgeons' non-technical skills in the operating room: reliability testing of the NOTSS behavior rating system. World J Surg. 2008 Apr;32(4):548-56.
6. Wilson R, Harrison B, Gibberd R, Hamilton J (1999) An analysis of the causes of adverse events from the Quality in Australian Health Care Study. Med J Aust 170(9): 411-415
7. General Medical Council (2013) Good medical practice. London, GMC

Competing interests: No competing interests

04 November 2016
YL Loo
Foundation Year 2 Doctor
C Chang, Research Fellow, Department of Plastic and Reconstructive Surgery, Pinderfields General Hospital, Wakefield
Pinderfields General Hospital
Pinderfields General Hospital, Wakefield