When Things Go Wrong in Healthcare

We Punish the Hands Holding the Swiss Cheese and Ignore the Factory That Makes It Full of Holes

Healthcare, for all its technology, is primitive in one key area: it cannot see its own systems. We measure people in detail but see systems only in outline. We have sharp tools for judging individual performance but almost nothing to monitor the health of the system itself.

This isn’t a small oversight; it’s a fundamental design flaw. It means that when harm occurs, we instinctively blame the person closest to the event, while the systemic failures that made the error inevitable remain hidden. This is best understood through the lens of the Swiss Cheese Model, which shows how disasters happen when holes in successive layers of defence line up.

In healthcare, however, we are conditioned to only see the final person holding the last slice of cheese. This article explains how this happens, why our focus is so dangerously narrow, and what it would take to finally see the whole system.

The Anatomy of a System Failure

Imagine a fatal medication error. A nurse is suspended after administering the wrong dose. The investigation concludes with “human error,” and the case is closed. This provides a sense of resolution, but it ignores the real story.

The story our system fails to record is that the high-concentration vial was stored next to the standard one (a latent error), the electronic warning was overridden due to alert fatigue (a design flaw), and the nurse was covering two units due to short staffing (an operational pressure). These are the holes in the Swiss cheese. The nurse didn’t cause the failure; they were the final person to inherit a chain of system-level defects.

The Loop of Blame

This is the loop of blame. Because we look for individual failings, we find them. Each investigation that ends by blaming a person strengthens the belief that error is a personal, moral failing. Hindsight bias makes it worse, turning a decision made under pressure and with incomplete information into an obvious mistake. We retrain the surgeon for a wrong-site surgery but leave the rushed, interruption-prone “time-out” process unchanged, ready to trap the next person.

Our system is wired with blinded sensors. It can detect the pharmacist or the nurse, but it is blind to the holes they are forced to work around: confusing packaging, similar drug names, and missing decision support. We punish the hands holding the cheese and ignore the factory that makes it full of holes.

A System Designed to Blame

This systemic blindness isn’t accidental; it’s embedded in our culture, structures, and tools.

Narrative Bias: Simple stories with villains are easier to tell and understand than complex stories of systemic failure. “The doctor forgot” is a simpler narrative than “The diagnostic pathway is fragmented across three different IT systems.”
Measurement Bias: It’s easy to count an individual’s errors. It’s far harder to measure team resilience, the usability of an electronic record, or the psychological safety of a ward. We manage what we measure, and we only measure people.
Accountability Structures: Our systems are built around individual responsibility.
- The name above the bed assigns responsibility to a single consultant, even if care is delivered by a sprawling, often disconnected team.
- Appraisals and job plans focus on personal activities and portfolios, not on the health of the teams or processes that individual works within.
- When a poor referral pathway leads to a delayed diagnosis, there is no clear owner to hold accountable, so we default to blaming the last clinician who saw the patient.

These forces relentlessly pull our attention toward the individual, pushing the system and its flaws into the background.

Developing System Sight

To stop blaming individuals, we must learn to see our systems. This requires a deliberate shift in focus, from punishing people to improving the conditions they work in. This isn’t about removing accountability; it’s about redefining it.

Embrace a Just Culture

First, we must adopt a Just Culture — a framework for differentiating between honest human error (which requires system redesign), at-risk behaviour driven by broken processes (which requires coaching), and genuine recklessness (which requires accountability). This gives us a way to be both compassionate and responsible, ensuring we only punish a conscious disregard for safety, not the predictable errors our own systems create.

A New Dashboard for Safety

Second, we need to track the vital signs of the organisation itself. The following are a few examples of metrics that can be used as early warning indicators of a system under stress, allowing us to diagnose problems before they cause harm (and there are many other system level metrics in healthcare):

System Stress & Staff Wellbeing: Regular, anonymous measures of burnout and fatigue are essential. A burned-out workforce isn’t a collection of personal failings; it’s a symptom of an overloaded system.
Improvised routines and variations in practice: Every time staff bypass a procedure, often out of necessity, it may signal a broken process. Workarounds should be logged and analysed, not ignored—and certainly not criticised by default. We must also check how often critical safety processes, such as surgical time-outs or patient handovers, are carried out as designed. This reveals the gap between “work as imagined” in protocols and “work as done” on the front line. The task is then to identify and address the underlying system-level causes of this difference.
Psychological Safety: Teams must feel safe to speak up and report errors without fear of punishment. Without this, data on safety is incomplete, because staff will only share good news.

Rapid and Accurate Differentiation of Error — emphasising the need to quickly and reliably distinguish between system-caused errors (the majority) and deliberate harm (a very small minority), since low specificity in this process causes unnecessary and damaging investigations, adding further psychological harm to both patients and staff.

Conclusion

Making the system visible is a duty of leadership. Boards and senior executives must review system health with the same seriousness they apply to finance. Their first question should not be, “Who was at fault?” but, “How did our system fail this patient and our staff?”

We have built a powerful machine for finding fault in people but remain blind to the systemic faults that produce that “human error.” This guarantees we will continue to find a final person to blame—the nurse who gave the drug, the surgeon who operated on the wrong site, the doctor who missed the critical detail. These people are not the cause of harm but its inheritors.

Punishing them does nothing to fix the chain of failure. It only ensures it will form again for the next patient, with a different person at its end. We see our people in fine detail, but our systems only in outline. Until we bring our systems into sharp focus, the next tragedy is not a matter of if, but of who.

From Blame to Systems Thinking: Tackling the Fundamental Attribution Error

Core Concept

The Fundamental Attribution Error (FAE) is a common but often overlooked cognitive bias with significant implications in surgical settings. It arises when we attribute colleagues’ errors or behaviours to personal traits or competence (e.g. “the surgeon is careless” or “the anaesthetist is incompetent”) while explaining our own errors by external circumstances (e.g. “The list was delayed because the first case was a complex obese patient and I lacked adequate assistance” or “I didn’t write in the notes because I was too busy with other patients”). Nowhere is this more evident than in poorly run M&M discussions, where the clinician under review often highlights external factors, while others focus on individual human errors.

Why It Happens in Surgery

The key issue is a failure to recognise that most imperfections or errors stem from the systems that govern the environment, rather than from inherent abilities or personal traits. In the operating theatre, pressures such as time constraints, hierarchy, ad-hoc teams, and limited awareness of colleagues’ workload, fatigue, or competing demands provide fertile ground for this bias.

Impact in the Clinical Environment

Unchecked, the FAE can directly undermine patient safety and team dynamics by:

Creating a blame culture: Focusing on individual fault instead of system flaws deters openness, learning, and improvement.
Damaging team cohesion: Even thinking of colleagues as “slow,” “inattentive,” “unreliable,” or “incompetent” undermines trust and erodes psychological safety.

Strategies to Mitigate FAE

Assume good intent – begin with the presumption that colleagues are competent and working in good faith.
Ask yourself structured, system-based questions such as: I)People: Was the team appropriately staffed and rested? Were roles clear? II)Tasks: Were protocols, checklists, or guidelines available and followed? (III)Environment: Was equipment functional and accessible? Were there distractions, interruptions, or time pressures? (IV)Communication: Was the handover complete? Was information shared clearly and consistently? (V)Organisation: Were scheduling, workload distribution, and support systems adequate?
Use of structured communication in regular face-to-face team meetings helps share context and reduce assumptions. Providing safe informal spaces, such as staff rooms where clinical teams can meet regularly over coffee, foster better understanding among colleagues.
Debrief with empathy – essential to an effective M&M process. Focus on what happened rather than who failed, ensuring all perspectives are heard.

Key Takeaway

When reflecting on our own shortcomings, the responsibility is twofold: to acknowledge our part honestly and to identify the system issues that contributed, so they can be addressed. Equally, when considering the errors of others, we have a duty to extend the same systems-based lens rather than defaulting to personal blame. By holding ourselves and our colleagues to this standard, we move from a culture of excuses or blame to one of shared learning and collective responsibility.

Embedding Safety in Action: Why Surgeons Should Embrace ‘Pointing and Calling’ in the Operating Theatre

In high-risk environments like the operating theatre, situational awareness and anticipatory thinking are essential. While standard safety protocols such as checklists and briefings are now routine, some surgeons have adopted an additional layer of safety: verbalising anticipated errors at key stages of surgery. This proactive technique, though informal and inconsistently adopted, has been observed to sharpen team focus, reduce the likelihood of mishap, and promote collective awareness during complex procedures.

It is therefore affirming to note that this very practice—known in Japan as Pointing and Calling (Shisa Kanko)—is already embedded and widely employed in high-stakes industries such as rail and aviation, where it has demonstrated striking effectiveness in reducing human error (https://youtu.be/RZun7IvqMvE?si=3TbWsamePGl9IFza).

What is Pointing and Calling?

Pointing and Calling involves physically pointing at a critical object or parameter and simultaneously verbalising its name or state before taking action. For example, a Japanese train driver will point at a speedometer and say the speed aloud before confirming a control input. This ‘ritualistic confirmation’ creates a multisensory engagement—visual, auditory, and motor—that improves attention and reduces oversight.

Evidence of Impact

Research from the Japanese Railway Technical Research Institute shows that Pointing and Calling can reduce errors by up to 85% in repetitive task settings. Additional studies confirm its utility even when tasks are routine or unchanged, due to its role in reinforcing attentional control and reducing cognitive slips. Notably, despite the extra physical actions involved, users do not report an increased sense of workload.

Parallels in Surgery

In surgery, a comparable practice already exists among some surgeons: deliberately verbalising the potential pitfalls or risks during distinct procedural phases. For example, a surgeon may say aloud, “This is the common bile duct—risk of injury here,” or, “Risk of bleeding as we divide this plane.” These utterances serve not only as personal prompts but also cue the entire team to heighten vigilance and anticipate the next steps.

Such verbalisation operates in the same cognitive space as Pointing and Calling—bringing intention and risk into the open, using the body and voice to anchor thought in action. It externalises awareness, reducing dependence on silent internal memory and instead engaging the collective focus of the operating team.

Why Broader Use Matters

Given the mounting complexity of modern surgery—minimally invasive techniques, robotic platforms, multidisciplinary teams—anything that enhances real-time safety awareness is worth pursuing. Pointing and Calling offers a structured, embodied tool for precisely that. Its broader use in surgical theatres could standardise the informal yet effective habits already in place among some surgeons.

The challenge may lie in cultural barriers: fear of seeming overly cautious, reluctance to appear theatrical, or simply unfamiliarity with the technique. Yet these can be addressed through training, modelling, and integration into existing safety culture.

Conclusion

Verbalising potential surgical mishaps is already practised with benefit by some surgeons. Recognising its alignment with the well-established method of Pointing and Calling in other high-stakes domains reinforces its value. Far from being superfluous, this embodied rehearsal of intention and caution should be viewed as a cognitive safety net—one we would do well to adopt more widely in the operating theatre.

Acute Limb Ischaemia

https://www.podbean.com/media/share/pb-wchij-aaf247

In this episode, Mr Afshin Alijani will be asking Mr Stuart Suttie, consultant vascular surgeon in Dundee, to describe the management of an acutely ischaemic limb. The topics covered include how to diagnose acute limb ischaemia from the history and examination, how to differentiate a salvageable from a non-salvageable ischaemic limb, and the technique of arterial embolectomy.

Abdominal Wall Closure

https://www.podbean.com/media/share/pb-dxb9a-aa14ac

The Lead article of the British Journal of Surgery Feb 2019 issue was on Abdominal Wall Closure. The author subsequently participated in a lively debate on #bjsconnect Twitter chat on 27.02.19. This podcast is a summary of that debate with a number of additions and expansions, including the Jenkins’ rule of wound closure and the appraisal of some the current evidence. Text and key references.

Abdominal Wall Closure

By Mr Afshin Alijani, Consultant Surgeon, Dundee

Reviewer: Mr Stuart Oglesby, Consultant Surgeon, Dundee

“Wound closure time is not coffee time” – This was the opening statement for the lead article of the February 2019 issue of the British Journal of Surgeon (@BJSurgery). The article was dedicated to the important topic of abdominal wall closure. The author, @acdebeaux subsequently participated in a lively Twitter chat at #bjsconnect on 27th February 2019. I have summarised some of the important aspects of that article and the debate which followed, with a number of additions and expansions.

Up to 20 percent of patients who undergo laparotomy will eventually develop incisional hernias. This translates into many thousands of cases of incisional hernia every year in the UK alone. As a result, any measure that results in even a very modest improvement in the rate of incisional hernia formation can reduce the number of patients suffering from the condition significantly. This is important because incisional hernias notably affect the patients’ quality of life, and surgical repairs put a large financial burden on the health service. There is a strong body of evidence to suggest that the technique used for the abdominal closure can greatly influence the rate of incisional hernia formation.

Several factors are needed for a wound to heal by primary intention, with minimal scarring and as quickly as possible. The clean wound edges need to be held apposed, without tension, until adequate amount of collagen is deposited. In health it takes around 3 weeks for the wound to develop enough tensile strength to remain closed independent of the suture material. This is why many surgeons prefer using slowly absorbable suture material, such as PDS, over rapidly absorbable material, such as Vicryl. Too much tension in the suture will render the wound ischaemic. The causes of this excess tension include obesity, over tightened suture, and abdominal distension following surgery. The patient also needs to have the ability to mount just the right level of inflammatory response for the process of healing. Diabetes, smoking and immunosuppressive therapy are known to dampen down this inflammatory response resulting in poor tissue healing. We also know that patients with defective connective tissue such as those undergoing open abdominal aortic aneurysm repair are at increased risk of chronic wound complications such as incisional hernias.

It is important to minimise the muscle mass enclosed within the suture bites to prevent tissue necrosis; since tissue necrosis can predispose to wound infection and hernia formation. It is reassuring that most of the tensile strength of the closure comes from the collagenous aponeurosis and not from the muscle. A wound disruption during the early postoperative period, also known as a burst abdomen, is more likely to be due to a technical failure. Possible reasons include knot failure or suture material cheese-wiring through the tissue. Late wound disruption can present as an incisional hernia. Although many incisional hernias are due to patient factors, it has been shown that with refined technique the incidence of incisional hernia can be significantly reduced.

In a landmark paper published in 1974 in the BJS, T.P. Jenkins showed the importance of wound to suture length ratio and how a ratio of 1 to 4 helped to reduce the rate of burst abdomens when compared to historical controls. The 1 to 4 rule states that for every cm of wound length, a minimum of 4 cm suture length should be used to ensure a sound tension free closure. Jenkins calculated that lower ratios such as 1 to 2 were associated with large rise in suture tension in the event of abdominal distension postoperatively. We simply do not know what percentage of surgeons currently follow this important rule since the wound to suture length ratio is rarely measured and recorded in the operation notes.

Identical wound to suture length ratio is achieved by either placing large bites far apart or small bites closer together. This has been the subject of a number of randomised controlled trials.

The STITCH trial published in the lancet in 2015 was a multi-centre Dutch study with 560 elective patients being randomised for either small or large bite laparotomy closure. The technique of small bite closure was first introduced by Israelsson in Sweden. In the small bite group, 5 mm thick and 5 mm apart sutures were placed using 2/0 PDS, against the control group of 1 cm bites that were 1 cm apart using heavier looped PDS. Patients were followed up for 12 months and were assessed with a combination of clinical and/or radiological examination looking for incisional hernias. The rate of incisional hernias were significantly reduced in the small bite arm of the trial from 21% to 13%.

Although the STITCH trial adds further evidence in favour of small bite closure, the findings need to be carefully appraised before the technique can be introduced widely. There are a number of methodological issues as well as narrow inclusion criteria that influence its generalisability. Firstly, the two arms of the trial differed in both the size of the tissue bite and the suture size. As a result, the findings could either be due to differences in tissue bites or suture sizes. Secondly, the wound to suture ratio should be 1 to 4 in both arms of the trial. However, the actual wound to suture ratio is 1:5 for the small bite and 1:4 for the large bite groups. Different wound to suture ratios may imply different suture tension in the two arms and hence introduces another extremely important variable not accounted for. Furthermore, the trial excluded emergency surgery and the obese patients. The mean body mass index of the patients was 24 with an upper limit of 27. And lastly, the follow-up of 12 months should be regarded as short. It is known that the incidence of incisional hernias nearly doubles at the 3 year follow up.

Despite these shortcomings, the trial is important in a number of ways. Firstly, it shows us how even small changes in the closure technique can have big effects on the rate of incisional hernia formation. We should all pay more attention to obtaining a 1:4 wound to suture length ratio. The calculated ratio should then be recorded in the operation notes. Secondly, it shows the safety of small bite technique, albeit in an elective normal weight patient population. Taking 5 mm bites is rather brave, particularly in the obese, but perhaps much larger bites closer to 2 cm are unnecessary and we should all be aiming for smaller tissue bites for abdominal closure.

Two further trials currently recruiting patients undergoing midline laparotomies are the continuous versus interrupted (or CONTINT) trial and Hughe’s trial. CONTINT is a German study comparing continuous running suture, using slowly absorbable suture, with interrupted suturing, using rapidly absorbable suture material. Hughe’s trial, on the other hand, is comparing mass closure with added interrupted tension sutures. Hughe’s trial allows the control (mass closure) arm to be the responsible consultant surgeon’s standard closure technique. You can immediately notice that these studies also suffer from the problem of having more than one main variable in each arm of the study.

In the #bjsconnect Twitter Chat, @acdebeaux discussed two further areas of interest. These included the growing evidence in favour of mesh primary closure for the obese patients, and the use of mesh sutures to replace current generation of suture material. Most of the evidence here

is of poor quality and we should await for further studies before making a definitive judgement on the use of mesh material for primary closure of the abdomen.

My impression is that the tightness of the closure is probably more important than the size of the suture bites. An overtightened suture causes ischaemia, particularly when muscle is included, resulting in eventual wound failure and incisional hernia formation.

In my opinion, there is a need for a paradigm shift in the way we view the abdomen. We should move away from viewing the abdominal wall as a tough mechanical barrier and instead we should think of it as a delicate and complex multilayered organ which is easily injured if not handled with care. We would exert more care during the closure and handle the abdominal tissue more delicately if we were to rebrand the technique as the “abdominal wall anastomosis”. Perhaps it is only then that we may stop thinking the wound closure time is coffee time.

Key References

A. C. de Beaux. Abdominal wall closure. BJS 2019; 106: 163-164.

Jenkins TP. The burst abdominal wound: a mechanical approach. Br J Surg. 1976 Nov;63(11):873-6.J

Deerenberg EB et al. Small bites versus large bites for closure of abdominal midline incisions (STITCH): a double-blind, multicentre, randomised controlled trial.
Lancet. 2015 Sep 26;386:1254-1260

Bile Duct Injury

Here I will be writing about bile duct injury and will focus on the human factors that have been shown to be the non-technical root causes. I will then list and explain the strategies to minimise the risk.

Bile duct injury still remains common compared to the era of open cholecystectomy. The overall rate of bile duct injury of all types in most large population based studies of laparoscopic cholecystectomy has been found to be around 0.4%. One in three surgeons will cause the injury during their working life time. Bile duct injury has a major detrimental effect on the patient’s physical and psychological wellbeing affecting their quality of life considerably and remains a common reason for medico-legal claims.

It is worth remembering that the majority of injuries are discovered postoperatively in cases described by the surgeon as otherwise straightforward. Even experienced surgeons are not immune from causing the injury. The injuries fall into a number of set patterns implying common underlying reasons. Injury to the bile duct is typically caused either due to poor technique or due to wrong identification of the anatomy. Poor technique includes causing bleeding intra-operatively, misuse of clips and electrocautery, and traction injuries. Poor technique tendS to manifest more in the presence of certain conditions such as acute cholecystitis, and obesity. However, the majority of severe injuries are due to non-technical causes.

In many of the severe bile duct injuries the root causes appear to be spatial disorientation and confirmation bias.

In the classic spatial disorientation, the surgeon mistakenly sees the bile duct as the cystic duct. This occurs when the Hartmann’s pouch is retracted towards the liver and not laterally as it should be, and as a result the cystic duct and the bile duct become aligned. Once the bile duct is mistaken as the cystic duct, the surgeon will subconsciously look for evidence to confirm rather than refute that his findings are correct. This is known as the conformation bias. The optical illusion thus created makes the bile duct appear as the cystic duct; and the bile duct is clipped and transected. The surgeon then continues the dissection up towards the liver for completing gallbladder dissection, only to come across a second structure, the common hepatic duct which is in turn transected.

So what are the surgical rules to follow to avoiding bile duct injuries caused by misidentification:

Rule number one during surgery is to bear in mind that you may be wrong in your assumptions about the anatomy. The easier the gallbladder appears to you, the more worried you should be that you may be looking at an optical illusion. Remember many major injuries are detected postoperatively in apparently easy gallbladders. The surgeon should not assume anything and should be consciously looking for evidence that refutes what he or she believes in. In other words you look for reasons why the cystic duct that you are dissecting could be the bile duct. This is not easy and goes against the natural tendency of looking for evidence that confirms that the cystic duct is indeed the cystic duct.

Rule number two is to have regular time outs to look out for key anatomical landmarks to re-orientate yourself. This is achieved by focusing the laparoscope out and to look for the liver sulcus, duodenum, porta hepatis, falciform ligament and liver. The timeouts need to be regular and frequent. Again this is important even if the gallbladder anatomy looks straightforward since you may be misreading the anatomy.

Rule number 3 is to achieve the critical view of safety. For this, the aim is to dissect the hepato-cystic triangle so that you have only two structures going into the gallbladder. The dissection needs to be extended for at least a third up the posterior gallbladder wall attachment to the liver to ensure no structures go back into the liver.

Rule number 4 “safety first, total cholecystectomy second”. in other words if you cannot confidently achieve the critical view of safety, then a bailout strategy is the correct action which means performing either a subtotal cholecystectomy or a cholecystostomy. In subtotal cholecystectomy, the anterior wall of the gallbladder is resected, stones removed and the gallbladder bed is drained. Some surgeons attempt to suture-close the cystic duct from inside once the anterior wall of the gallbladder is removed. It is essential that you place drains into the gallbladder area even in the absence of any visible bile leak, since once the inflammation subsides the cystic duct could open up and start leaking bile postoperatively. Often a number of drains are placed, including one to the gallbladder bed, one to the foramen of Winslow posterior to port hepatis and the other placed under the live laterally.

Most low volume bile leaks following subtotal cholecystectomy subside spontaneously but if there is large volume or prolonged period of bile leak, you may consider an ERCP and stenting. This usually results in a rapid resolution of the leak.

So what should you do if you find yourself in the unfortunate situation of having caused a bile duct injury during surgery.

2 things are required:

First, you should not attempt to do any further dissection as this will either extend the injury or devascularise the bile duct. Conversion to open surgery is not indicated either. Instead you should communicate your concerns with the theatre team clearly, and have a time-out or de-scrub.

Second, you should discuss the problem with an experienced HPB surgeon. The evidence suggests that the best surgical outcomes come from repairs done at the time of the index operation by an experienced HPB surgeon. The HPB surgeon is very likely to perform an intra-operative cholangiogram before deciding on the type of repair. In most cases the choice of repair is a hepatico-jejunostomy. However, You may have to transfer the patient to a tertiary centre if no expertises exists locally. The abdomen needs to be adequately drained prior to the transfer and clear operation notes detailing all the operative events should be recorded in the patient’s medical files before the transfer.

Bile Duct Injury

https://www.podbean.com/media/share/pb-bmk6v-a8a1d1

In this episode, Mr Afshin Alijani, a consultant surgeon at Ninewells Hospital, Dundee will be talking about bile duct injury. He will describe the two main root causes for sever injuries, namely disorientation and confirmation bias. Four surgical strategies are then offered to avoid such errors. The talk will conclude with a description of what to do intra-operatively in case of an injury to the bile duct.

Bile Duct Stones

https://www.podbean.com/media/share/pb-wb4b6-a6fef0

In this episode, Mr Afshin Alijani, and Mr Pradeep Patil (consultant surgeons at Ninewells Hospital, Dundee), discuss the management of bile duct stones. For key papers please click here.