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see the patient prior to discharge. This behavioral
deficiency may not have occurred if the handoff had
been more comprehensive. Regardless of the quality
of the handoff, and even if the findings at the bedside
led to discharge, diligent behavior required a clinical
assessment. This exemplifies how so often more than
one part of a system has to fail before an error leading to injury occurs. It also emphasizes the surgeon’s
critical place within systems of care.
The on-call surgeon made additional behavioral errors in the ED, including failure to pursue
an abnormal test and failure to cross-cover and provide continuity of care. These breakdowns may have
been caused by fatigue while taking weekend call.
Alternatively, and more incriminating, the behavior
may have resulted from the fact that the patient did
not “belong” to the call partner.
Human factors like fatigue, attitude, and competing priorities can affect cognition and behavior.
The surgeon cherry-picked the available data, favoring the patient’s relatively mild subjective clinical
presentation—99 degree temperature, moderate
pain and tenderness, satisfactory blood pressure and
pulse, minimal elevation of the WBC count—over
the objective findings of excessive free air and leaking contrast. The delay in treatment led to organ
system failure and the dramatic escalation of the
consequences of the anastomotic leak. As is so often
the case, the technical error alone might have been
effectively managed with acceptable temporary, albeit
significant, consequences, but adding behavioral violations and cognitive mistakes stemming from lack of
diligence as second, third, and fourth errors created
an unacceptable perfect storm.
Surgeons are subject to fatigue, distractions, time
constraints, competing priorities, workload, burnout,
and other factors that occasionally affect our professional behavior and cognition. Certainly, other
variables over which we have little or no control can
adversely affect our success at the point of service.
Nonetheless, deficiencies in professional behavior and
cognition are frequent, avoidable causes of errors. ♦