Elsevier

Surgery

Volume 133, Issue 6, June 2003, Pages 614-621
Surgery

Surgical Outcomes Research
Analysis of errors reported by surgeons at three teaching hospitals*,**,

https://doi.org/10.1067/msy.2003.169Get rights and content

Abstract

Background. Little is known of the factors that underlie surgical errors. Incident reporting has been proposed as a method of obtaining information about medical errors to help identify such factors. Methods. Between November 1, 2000, and March 15, 2001, we conducted confidential interviews with randomly selected surgeons from three Massachusetts teaching hospitals to elicit detailed reports on surgical adverse events resulting from errors in management (“incidents”). Data on the characteristics of the incidents and the factors that surgeons reported to have contributed to the errors were recorded and analyzed. Results. Among 45 surgeons approached for interviews, 38 (84%) agreed to participate and provided reports on 146 incidents. Thirty-three percent of incidents resulted in permanent disability and 13% in patient death. Seventy-seven percent involved injuries related to an operation or other invasive intervention (visceral injuries, bleeding, and wound infection/dehiscence were the most common subtypes), 13% involved unnecessary or inappropriate procedures, and 10% involved unnecessary advancement of disease. Two thirds of the incidents involved errors during the intraoperative phase of surgical care, 27% during preoperative management, and 22% during postoperative management. Two or more clinicians were cited as substantially contributing to errors in 70% of the incidents. The most commonly cited systems factors contributing to errors were inexperience/lack of competence in a surgical task (53% of incidents), communication breakdowns among personnel (43%), and fatigue or excessive workload (33%). Surgeons reported significantly more systems failures in incidents involving emergency surgical care than those involving nonemergency care (P <.001). Conclusions. Subjective incident reports gathered through interviews allow identification of characteristics of surgical errors and their leading contributing factors, which may help target research and interventions to reduce such errors. (Surgery 2003;133:614-21.)

Surgery 2003;133:614-21.

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)

    *

    Funding provided by the Warren Whitman Richardson Fund at Harvard Medical School

    **

    Reprint Requests: Atul A. Gawande, MD, MPH, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02155.

    0039-6060/2003/$30.00 + 0

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