Patient safety literature is filled with references to aviation accidents and safety. Probably the most often cited accident is the crash of United Airlines flight 173, which occurred in December 1978.

As the plane began its approach into Portland, Ore., it appeared that one of the main landing gears had not deployed properly. It was not clear whether the problem was with the gear itself or with the gear indicator lights. The pilot became preoccupied with troubleshooting the gear problem.

Concurrently, the first officer and the flight engineer noted the aircraft’s dwindling fuel status. Their comments became more strident as the fuel status became more precarious, but the pilot remained focused on the landing gear problem. The plane crashed 6 miles short of the approach end of the runway, and 13 people died.

A number of survivors, however, including some of the crew, allowed a very thorough analysis of the causes of the crash, which became one of the most studied, seminal accidents in the redesign of aviation safety.

Transferring lessons learned
So what has this to do with orthopaedic surgical safety? The AAOS Patient Safety Committee has identified the following six critical components of surgical safety: consent, confirmation, communication, consistency, concentration, and collection. The experience of United 173 illustrates failure in two of these areas—communication among crew members and concentration on the task at hand.

The crash investigation focused on the lack of effective communication among the three crew members about the urgency of the fuel situation. It also noted the pilot’s lack of concentration on his primary task—flying and safely landing the airplane.

As orthopaedic surgeons, we must remember that our primary task is to bring our patients safely through their surgeries. The purpose of this article is to focus on the concentration component of surgical safety.

Many factors may affect concentration. Substance abuse—the use of drugs or abuse of alcohol—may be the first factor we think of. It should be self-evident that this impediment to concentration should never occur.

Among other factors that can affect concentration, perhaps the most common is fatigue. The current limitations on resident work hours are the result of extensive study on fatigue-related errors among hospital staff. But once a surgeon completes training, no work hour limitations currently exist.

Fatigue can result from lack of sleep, long distance travel, illness, or simply cumulative overwork. Regardless of the cause, fatigue prevents effective focus on the task at hand and disrupts concentration. Because no rules or standards exist, self-regulation becomes necessary. A surgeon who is tired, before beginning any surgical procedure, must always ask himself or herself, “In my current state of fatigue, can I concentrate effectively enough to perform this procedure in a safe manner?” If the answer is no, the procedure should be postponed until the surgeon is rested and better able to concentrate or the patient should be referred to another surgeon.

Continuation bias
Continuation bias is another important area in which concentration is relevant. This concept is illustrated in industry when the completion of a project becomes so central and important that pertinent factors that might prevent completion of the task are denied or ignored. The pilot of United 173 was so focused on troubleshooting the landing gear problem that he ignored the fuel issue.

Continuation bias can be found in the operating room (OR) when surgeons are so focused on completing the procedure that they ignore unusual factors that would cause them to deviate from a routine surgical technique, thereby compromising the result. Concentrating on the sequential steps of a procedure, rather than hyperfocusing on the end, enables surgeons to adapt to any deviations that may arise and prevent complications at an earlier stage.

Simply following sequential steps, however, can also be problematic. Following “standard operating procedures” may ensure consistency but may also breed complacency. After performing a thousand carpal tunnel releases in exactly the same fashion, a surgeon may not bring the same degree of concentration and caution to release number 1,001 than he or she might to a less familiar procedure. The need for concentration to detail is as important in familiar or “standard” procedures as in new ones.

Task saturation
Task saturation is another concept from industry that can be applied to surgical safety. According to Suzanne Gordon, author of Beyond the Checklist: What Else Health Care Can Learn from Aviation Teamwork and Safety, information overload and inadequate prioritization of inputs can both lead to task saturation. Although people commonly talk about multitasking, in reality, people cannot really multitask. What actually happens is “single-tasking” in sequence, sometimes rather haphazardly.

Task saturation results from having too much to do and not enough time to do it. The ability to manage task saturation requires concentration on “triage” information input based on importance and to develop techniques for analyzing and acting on those inputs.

A final word on distraction, which for the purposes of surgical safety is essentially the opposite of concentration: Distractions can be internal or external and can range from something as simple as music in the OR or a beeper or cell phone ring, to something as complex as difficulties with a spouse or family member. The newest OR distraction, at least for OR nurses, may be electronic medical records.

It is the job of each individual on the OR team to exclude and/or limit distractions. The way to address this problem is for each member of the OR team to be focused and on task, particularly at critical junctures of the procedure.

Joe B. Wilkinson, MD, FACS, is a member of the AAOS Patient Safety Committee and a senior aviation medical examiner for the Federal Aviation Administration. He can be reached at jwilkinson@wtmedical.com

Editor’s note: This is the second in a series of articles from the AAOS Patient Safety Committee on improving surgical safety by focusing on the six Cs: Consent, Confirmation, Communication, Consistency, Concentration, and Collection.

Additional Information
Orthopaedic Surgical Consent: The First Step in Safety
AAOS Summit Shines Light on Surgical Safety
AAOS Hosts Orthopaedic Patient Safety Summit