Cutlery Science*

29 March 2022

To get back to the parallels between surgery and safety science I’d like to discuss an issue with respect to surgical instruments. During surgery you need surgical instruments to do your work. Although that seems to speak for itself, there is quite some thinking involved. First, what does the procedure itself require? What problems could be encountered that needs to be anticipated upon? For example: it may bleed, and thus certain clamps may come in handy to stop the bleeding. Or a large gauze. Preparing for surgery also means you think ahead and weigh risks, just as when you consider diagnoses; what is the worst that could happen? And what is the most likely that to occur? And not unimportant; how fast do I need which additional instruments? Should it be ‘just’ around or on the table? How is the logistics of the OR designed? Sheer balancing, weighing risks, making trade-offs. 

Now most of us regular surgeons are spoiled, because standardized sets are available for each procedure, usually established by operating-theatre nurses together with leading surgeons. But surgeons each have their own preferences and priorities that usually leads to an expansion of available instruments on those sets. In itself, personal preferences are not strange at all, even valid, since each craftsman likes to use their own instruments for optimal performance. But it conflicts with the advantages of having standardized ‘sets’ of instruments used for each surgery, independent of the individual surgeon. This conflicting between standardization and autonomy occurs a lot in healthcare by the way, but more on that later. The net result meanwhile, is that a standardized set of instruments usually contains way too many instruments, respecting all wishes and demands, sometimes even traditions. I have encountered pieces that belong in museums, that were cleansed with each surgery and not-used again. My attempts to let those disappear usually failed because nurses count instruments after surgeries. 

That is why an appreciated colleague from Groningen, professor Joost Klaase, has worked already for many years to critically evaluate standardized sets of surgical instruments, in collaboration with the Twente Technical University. What can be left out, what is essential, how to organize seldomly needed materials. In short, how to be smart? That process is very similar to doing a risk-analysis, to applied safety science. But why should you not just put ‘everything on the table, just to be sure’? What is wrong with ‘staying on the safe side’? Well, because it is sham safety. With too many instruments around, you might not be able to find that one clamp you really need. And it is a waste of resources. Mind you, it involves millions each year. Multiple safety experts could be hired each year from those savings. And not in the least, it shows a lack of active thinking, a lack of understanding and control of the risks we should be anticipating on. And being thoughtless, even clueless, is in general not good for our shared safety. 

That is why I would like to thank everyone who keeps working on improving the issue with surgical instruments sets, and please, do not give up. It is low-hanging fruit, and it does not only show that safety thinking leads to savings, but also leads to improved real safety. Less is more. 

With many thanks to Ron, an appreciated, self-appointed ‘cutlery-nurse’ from the Spaarne hospital, to whom I owe a lot of learning during my surgical training. Also thanks to Paul, who inspired me to emphasize the idea that safety leads to savings.