Patient safety in surgery: strategies to achieve the best outcome in the high-risk surgical patient

High-risk surgery is conducted in the margins of rule-based and evidence-based Safety-I practice, often on patients who are older or frail, with multiple co-morbidities. In this chapter, we present tools for thought and reflection that may be of use at and beyond the frontier of Safety-I into Safety-II space, where risk can be high and surgical outcomes less controllable or predictable. We set the scene by providing background material on the nature of the complex adaptive system in which high-risk surgery is transacted. We then introduce the reader to two ideas that underpin complexity and help frame the high-risk surgical context: Snowden’s Cynefin framework and McGilchrist’s concept of the divided brain. Having set the high-risk surgical context firmly in complexity, we then consider the risk to the patient from first consideration of surgery, through the preparation and the consent, the surgical procedure itself, and finally to debriefing and learning. The chapter includes tips and tools for reducing risk and keeping the patient safe, and a discussion on the pros and cons of the surgical checklist. We finish with two important, overriding principles, the classic ‘gold’ and ‘silver’ rules, that may be useful when contemplating surgery on the high-risk patient: treat another as one would be treated oneself, and do not do to another what one would not have done to oneself.