Surgical outcomes researchError or “act of God”? A study of patients' and operating room team members' perceptions of error definition, reporting, and disclosure
Section snippets
Population and sample
The study population consisted of operating room (OR) team members (general surgeons, nurses, anesthesiologists) and patients from 2 Canadian quaternary care university-affiliated hospitals. The study was reviewed and approved by both hospitals' research ethics boards, and consent was obtained from all study participants.
Homogeneity within each health care discipline was assumed, allowing for a minimum of 5 to 8 participants20 each from the departments of surgery, nursing, and anesthesiology.
Error definition
There were no significant differences among the 4 groups (surgeons, nurses, anesthesiologists, and patients) in their overall frequency of calling an event an error ( = 1.47, P = .83). Across the 4 groups, 97% of the participants deemed the events of scenarios 1 and 2 as errors and 90% perceived the events of scenario 4 as an error. Scenario 3, the dropping and marking of the specimen, was more ambiguous, with only 40% of the participants calling it an error.
The shared perception of what
Discussion
This study yielded new insight into the common justifications used by professionals and patients to explain why they perceive some and not other events as errors. We found both similarities and differences between professionals and patients regarding error, reporting, and disclosure. Together, the data serve to show the distance that remains between current perceptions and a safety-conscious health care culture.
Our first important finding was that surgeons, anesthesiologists, and nurses were
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Supported through a studentship by the Ontario Student Opportunity Trust Fund—Hospital for Sick Children Foundation Student Scholarship Program (S.E.); the Richard and Elizabeth Currie Chair in Health Professions Education Research (G.R.); and a CIHR New Investigator Award and the BMO Financial Group Professor in Health Professions Education Research (L.L.).