Analysis of Errors Reported by Surgeons at Three Teaching Hospitals

Published In: Surgery, v. 133, no. 6, June 2003, p. 614-621

Posted on RAND.org on December 31, 2002

by Atul A Gawande, Michael J Zinner, David M. Studdert, Troyen A Brennan

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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, the authors 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.

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