Surgical Outcomes ResearchAnalysis of errors reported by surgeons at three teaching hospitals*,**,★
Section snippets
Overview and definitions
Interviews lasting approximately 1 hour were conducted with attending surgeons, senior surgical residents, and surgical fellows at three Massachusetts teaching hospitals. We used the interviews to elicit reports on any of the interviewees' cases in which: (1) an adverse event occurred, meaning an injury involving disability (temporary or permanent) or death that resulted from medical management, as opposed to disease;26 (2) the surgeon was personally aware of the circumstances that led to the
Results
Thirty-eight of the 45 surgeons we approached agreed to participate in the study (participation rate = 84%). In interviews, these surgeons reported one to eight incidents each (mean 4, standard deviation 1.9), providing a total of 146 different incidents for analysis. Fourteen incidents were reported by more than one surgeon.
Fifty-five percent of incidents came from review of interviewees' complications reported at M&M conference during the previous 6 months; of 235 M&M cases reviewed, 34% met
Discussion
We found that confidential interviews with surgeons successfully elicited detailed reports on a large number of surgical adverse events resulting from errors in care. The incidents reported were serious, with one third resulting in permanent disability and 13% in death, and we were able to identify important underlying patterns in the errors.
Contrary to the premises of malpractice law, the vast majority of errors did not appear to be solely the result of individual failure.33 We found that the
Acknowledgements
The authors have no known financial or other conflicts of interest in conducting or reporting this work.
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Cited by (0)
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Funding provided by the Warren Whitman Richardson Fund at Harvard Medical School
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Reprint Requests: Atul A. Gawande, MD, MPH, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02155.
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0039-6060/2003/$30.00 + 0