Disasters of endoscopic surgery and how to avoid them: Error analysis

For every innovation there are two sides to consider. For endoscopic surger y the positive side is more comfort for the patient, and the negative side is new complications, even disasters, such as injuries to organs (e.g., the bowel), vessels, and the common bile duct. These disasters are rare and se ldom reported in the scientific world, as at conferences, at symposiums, an d in publications. Today there are many methods for testing an innovation ( controlled clinical trials, consensus conferences, audits, and confidential inquiries), Reporting "complications," however, does not help to avoid the m. We need real methods for avoiding negative failures. The failure analysi s is the method of choice in industry. If an airplane crashes, error analys is starts immediately. Humans make errors, and making errors means punishme nt. Failure analysis means rigorously and objectively investigating a clini cal situation to find clinical relevant information for avoiding these nega tive events in the future. Error analysis has four important steps: (1) Wha t was the clinical situation? (2) What has happened? (3) Most important: Wh y did it happen? (4) How do we avoid the negative event or disaster in the future. Error analysis has decisive advantages. It is easy to perform; it s upplies clinically relevant information to help avoid it: and there is no n eed for money. It ran be done everywhere; and the information is available in a short time. The other side of the coin is that error analysis is of co urse retrospective, it mag not be objective, and most important it Rill pro bably hare legal consequences. To be more effective in medicine and surgery we must handle our errors using a different approach. According to Sir Kar l Popper: "The consituation is that we have to learn from our errors, To co l er up failure is therefore the biggest intellectual sin.".