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Indian Journal of Surgery
Medknow Publications on behalf of Association of Surgeons of India
ISSN: 0972-2068
Vol. 66, Num. 1, 2004, pp. 15-18
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Indian Journal of Surgery, Vol. 66, No. 1, Jan-Feb, 2004, pp. 15-18
Review Article
Reporting surgical errors: Myth or reality?
Kaushik Bhattacharya, A. Neela Cathrine
Department of Surgery, Sri Ramachandra Medical College & Research Institute,
Chennai - 600116, India.
Address for
correspondence: Kaushik Bhattacharya, A-5,208 HIG TNHB Flats, Anna Main Road,
K. K. Nagar (W), Chennai -
600078, India. E-mail: kaushik_srmc@rediffmail.com
Paper Received: May 2003. Paper Accepted: October 2003. Source
of Support: Nil.
Code Number: is04004
ABSTRACT
Medical errors have now been listed as an important cause
of death, and are manifest in the numerous litigations that occur in the present
day. Reporting of errors includes the mildest of complications like increased
hospital stay to the most serious like death. A review of literature indicates
that most institutions do not report serious complications due to fear of liability
and loss of reputation. Interpersonal relationships between physician and patient
and adequate counselling of the patient all seem to influence the patient's
decision to sue the surgeon. Mandatory reporting may be necessary to limit
errors but its major fallacy includes the lack of immunity of staff from litigation
and public harassment.
Key Words Surgical errors, Mandatory reporting, Intraoperative death.
How to cite this article: Bhattacharya K, Cathrine AN. Reporting surgical
errors - Myth or reality? Indian J Surg 2004;66:15-8.
INTRODUCTION
"Make it compulsory for a doctor using a brass plate
to have inscribed on it, in addition to the letters indicating his
qualification, the words `Remember that I too am mortal'"
_ G. B. Shaw (1913)
Surgical errors causing either injury or death of patients
can ruin professional reputation and career, endangers the trust that patients
have in medical care professionals and are presently costly due to consumer
courts. In the U.S., between 44,000 and 98,000 patients die each year as a
result of medical errors, which exceeds the 8th leading cause of death (suicide).1 Malpractice
litigations are associated not only with physician or surgeon's negligence
and error but also with the quality of communication between the doctor and
the patient. A review of the current literature dealing with surgeon's error
or misjudgement and the factors responsible for and against reporting such
adverse events is done.
COMPLICATION REPORTING IN SURGICAL LITERATURE
Although short term postoperative outcomes such as
operative time, estimated blood loss, blood
transfusion, length of hospital stay and time to return to work
have been reported, death and complication rates
within both hospital and medical literature still
deserve consistency and clarity in reporting.
Incomplete records, multiple sites of postoperative
care, medicolegal concerns regarding documentation
of patient safety issues and worry over public
disclosure of data often hinder the accurate portrayal of
the postoperative course and consequent tabulation
of data.
In a study analyzing 119 articles reporting outcomes of 22,530
patients which included 40 studies of pancreatectomy, 35 oesophagectomy articles
and 44 pertaining to hepatectomy (42 were prospective randomized controlled
trials and 77 retrospective series), it was concluded that outpatient information
(22% of articles), definition of complications provided (34% of articles),
severity grades used (20% of articles) and risk factors included in analysis
(29% of articles) were the most commonly unmet quality reporting criteria.
Type of study (randomized controlled trial -vs- retrospective), site of institution
(US -vs- non US) and journal (US -vs- non US) did not influence the quality
of complication reporting.2
In hospitals, staff members usually fail to report incidents
due to time pressure, fear of punishment and lack of a perceived benefit. Shame
and fear of liability, loss of reputation and peer disapproval are particularly
strong disincentives among medical professionals. Hospitals also fear public
disclosure of reports, with damage to their reputation, loss of business and
litigation.
DISCLOSURE OF INTRAOPERATIVE DEATH
The surgeon must help the patient understand both what is
planned preoperatively and how treatment is proceeding. The extent of disclosure
is generally decided by the surgeon and that should include diagnosis, treatment
planning and outcome. The surgeon is not expected to give the patient a "mini
medical education" or even everything that is known about the iatrogenic
complication but the patient should be told about the risk of complication
involved in the proposed treatment and the actual outcome of one's treatment.
In case of intraoperative error, the surgeon's postoperative care should include
additional evaluation procedure and response which should be shared with the
patient or patient's surrogate in the early postoperative period. However,
underdisclosure of such errors may be even more anxiety - provoking for the
family and patient, inducing fears that the complications were worse than they
really were.3
A Canadian study examined 192 general surgery patients for
1277 days and reported that 39% of patients suffered from a total of 144 complications.
Two of these complications were fatal and 10 were life threatening. An interesting
feature of the study was while 80% of these adverse events were neither reviewed
during morbidity or mortality rounds, 95% were not recorded on the discharge
summary of the patients.4
SURGEON'S TONE OF VOICE
Interpersonal aspects of care, such as quality of communication
between physician and patient may be central to the patient's decision to initiate
malpractice litigation. The manner or tone in which a surgeon communicates
might have an important bearing on physician-patient relationship. In a landmark
first ever study investigating surgeon's tone of voice during routine office
visits and their malpractice claims history on 57 surgeons (23 were general
surgeons and 34 were orthopaedic surgeons), it was seen that surgeons who were
judged to be more dominant (OR 2.74, p = .02,
95% CI 1.16 - 6.43) and less concerned/ anxious
on the basis of their tone of voice were more likely
to have been sued than surgeons who were judged to
be less dominant and more concerned/ anxious. The
result did not vary according to the speciality of the
surgeon (orthopaedic -vs- general). Thus it was concluded
that dominance coupled with a lack of anxiety in the
voice may imply surgeon indifference and lead a patient
to launch a malpractice suit when adverse outcomes occur. This study also emphasized
the selection, training and continuing education of surgeons, as there is
little literature that specifically examines
surgeon-patient relations or that provides guidance for how to
improve their communication. The authors recommended
an effective training method with the use of
audio-taped interactions for feed back and to provide surgeons
with a sense of how they sound during interactions
with patients.5
REPORTING OF ADVERSE EVENTS AND ERRORS
Adverse events have been defined as injuries related to medical
management (in contrast to complications of disease). Error has been defined
as "the failure of planned action to be completed as intended (error of
execution) or use of a wrong plan to achieve an aim (error of planning)".
The primary purpose of voluntary reporting is6
- To learn from experience
- All responsible parties are aware of major hazards
- Monitoring progress in prevention of errors
- To hold hospitals accountable for safe practices
In a study on 218 completed questionnaires sent randomly to
surgeons listed in the American College of Surgeons 1998 year book, participants
were asked to read two scenarios in which an adverse event occurred during
the surgical management of patients. The average age of the respondents was
49.2 years (minimum 38, maximum 68), and 91% were males. The majority were
general surgeons (36%), followed by plastic surgery (12%) and otolaryngology
specialists (8%). 26% of the respondents indicated that they believed, reporting
the incident to the patient would result in litigation against them, regardless
of where the initial surgery was performed whereas two- thirds of the respondents
(62%) believed that reporting such events would result in improved patient
care in future. Approximately 75% of respondents indicated that they believe
that the use of surgical protocols would lessen the incidence of errors while
the rest felt that errors typically results from lack of training and personnel
shortages, rather than the absence of protocols
or standard procedures, and that the use of protocols
may encourage staff to "stop thinking". Few respondents felt that while
surgical protocols may reduce errors, they may also encourage litigation if they
are not precisely followed, regardless of whether
adverse events occur or not.7
VOLUNTARY EXTERNAL REPORTING SYSTEMS
In the US, there are five major national voluntary reporting
systems The Joint Commission on Accreditation of Healthcare Organisation (JCAHO),
Sentinel Events reporting Programme, the Medical error reporting programme,
the Med MARx programme and the National Nosocomial Infection Survey.The last
three are designed along with the pattern of the famous Aviation Safety Reporting
system of Charles Billings.8 Adverse drug events, drug reactions,
medication errors, drug name, labelling and packaging hazards and hospital
- acquired infections are reported to them. As such they are the most successful
voluntary programmes as they are safe, simple and worthwhile. Expert analysis
is available and specific directions to improve health care are recommended.
But then to set up a national voluntary reporting system would be a daunting
task. Studies estimate that 1 million serious error- related adverse events
occur annually.9,10 If "close calls" were also reported,
the total would be around 5 million.11 Even if only 10% of errors
were reported, the number 500,000 is 15 times the number processed by the Aviation
Safety reporting system. Such number would entail high cost of processing,
delay in analysis, risk of breach of confidentiality and as such render reporting
futile.
MANDATORY REPORTING - CURRENT CONTROVERSY
The Institute of Medicine (IOM) in US defines mandatory reporting
systems as systems run by State department of health that require hospitals
to report serious accidents and threats to patient's safety. Mandatory reporting
of serious injuries primarily improves safety by ensuring accountability.9 However,
the American Medical Association and the American Hospital Association raised
strong reservations against mandatory reporting as they felt that it would
increase liability and drive reporting underground. Mandatory reporting system
hold hospitals accountable by
requiring that serious mishaps be reported and
by providing disincentives, such as penalties or
sanctions, for continuing to engage in unsafe practices. It
also provides valuable information, to many other institutions if the lessons
learned from serious accidents are widely shared. However, common
arguments against mandatory reporting were
- It may increase the pressure to conceal, rather than analyze
errors.
- Reporting is cumbersome and time consuming, carries the
risk of loss of license or accreditation.
- Most reports elicit no response and the lessons learned
from investigation are seldom shared, hospitals often view reporting
as all risk and no gain.
- Reporting will not work in the present legal system, though
no studies have ever linked any association between reporting and
litigation. Ironically, few reports only indicated that full disclosure of
events
reduces the risk of litigation.12
The successful and ideal reporting system should be non-punitive,
confidential, independent, timely, system-oriented, responsive and evaluated
by experts who understand the clinical circumstances and who are trained to
recognize underlying systems causes.
In US, the National Quality Forum report has listed the following
surgical events as mandatory reportable events13
- Surgery performed on the wrong body part
- Surgery performed on the wrong patient
- Wrong surgical procedure performed
- Retention of foreign object in a patient after surgery or
another procedure.
- Death of ASA Class I risk patient during or immediately
after surgery.
The future of mandatory reporting is controversial. Mandatory
reporting is no substitute for a good relationship between surgeon and patient.
Few factors such as critical shortage of trained nurses, temporary or float
personnel in high risk areas such as operating room or casualty, and cost pressures
influence the ability of committed surgeons to limit or report errors. According
to Marshall Marinker, the task of specialist is to "reduce uncertainty,
to explore possibility, and to marginalize error. That of general practitioner
is to mediate between predicament of the individual and the potential of the
bioscience i.e., to tolerate uncertainty, explore probability and to marginalize
danger."14
Finally, the Institute of Medicine report in 2001 concluded
- `Healthcare today harms too frequently and routinely fails to deliver its
potential
benefits'.15
CONCLUSION
When guidelines have been established that certain wrongs
have to be mandatorily reported, then it is definite that such wrongs do occur.
Reporting those errors still seem to be in its infancy, with the majority of
surgeons fearing slander, vindictive action, litigation and even delicensing
of practice. A minority seem to believe that errors are mainly because of problems
in the system, and not directly related to surgical / medical skill per se.
As long as the care-giver is considered part of a consumer
market, where admitting that he has erred would penalize him, mandatory / voluntary
reporting cannot be implemented. Audits conducted in small circles strictly
in confidence, with additional emphasis on good surgical training, accurate
diagnosis and planning treatment within means, may restrict the number of medical
errors.
Reporting adverse events and means to overcome or prevent
such events will definitely go a long way in improving knowledge and ultimately
patient care. But that can materialize only if at least scientific fora and
academic discussions are made exempt from public consumption, where medical
personnel can discuss problems without the Democle's sword of litigation hanging
over their necks.
"From the time of Hippocrates, surgery has ever been
the salvation of inner medicine. In inner medicine, physicians have
dwelt too much in dogmas, options and speculations; and too often their
errors
passed
undiscovered to the grave. The surgeon, for his
good, has had a sharper training on facts, his errors hit
him promptly in the face."
_ Thomas Allbutt (1922)
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- Bates DW, Cullen DJ, Laird N, Petersen LA, Small SD, Servi
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be the best policy. Ann Intern Med 1999;131:963-7.
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- Institute of Medicine Committee on Quality of Health Care
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© 2004 Indian Journal of Surgery.
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