Analysis of errors reported by surgeons at three teaching hospitals.
By A. Gawande, M. Zinner, D. Studdert, T. Brennan. Surgery, 2003
1,088 citations recorded by the source corpus.
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.
Subfields: Emergency Medical Services, Emergency Medicine, Surgery
View Paper: https://www.semanticscholar.org/paper/76bee05a0946f16fd07b9e9a404f070e03e72b3e
How researchers see this paper
The researchers whose trusted networks rank it highest, strongest advocate first. Every researcher gets a different order.
In Emergency Medical Services
In Surgery
Citations in the corpus
- Patterns of communication breakdowns resulting in injury to surgical patients. (2007, methodology): “These ere based on a review of the literature and findings rom previous field studies.(3,5) The list of categories was lso examined by an expert in human factors analysis for ompleteness.”
- Evaluation of a preoperative checklist and team briefing among surgeons, nurses, and anesthesiologists to reduce failures in communication. (2008, neutral): “implement a preoperative checklist designed to support a team briefing in the operatingroom(OR),(2)toobjectivelyassess whether the checklist briefings reducedcommunicationfailures,and( 3 )to characterizetheprecisenatureofimprovement in communication associated with this intervention.”
- Non-technical skills for surgeons in the operating room: a review of the literature. (2006, background): “In a recent study, communication was found to be a causal factor in 43%of errorsmade in surgery.(3) Another study reports that 27%of claims against a health care organization resulted from cognitive and diagnostic errors in the operating room.”