title: Prospective, multidisciplinary recording of perioperative errors in cerebrovascular surgery: is error in the eye of the beholder?
abstract: OBJECT Surgery requires careful coordination of multiple team members, each playing a vital role in mitigating errors. Previous studies have focused on eliciting errors from only the attending surgeon, likely missing events observed by other team members. METHODS Surveys were administered to the attending surgeon, resident surgeon, anesthesiologist, and nursing staff immediately following each of 31 cerebrovascular surgeries; participants were instructed to record any deviation from optimal course (DOC). DOCs were categorized and sorted by reporter and perioperative timing, then correlated with delays and outcome measures. RESULTS Errors were recorded in 93.5% of the 31 cases surveyed. The number of errors recorded per case ranged from 0 to 8, with an average of 3.1 ± 2.1 errors (± SD). Overall, technical errors were most common (24.5%), followed by communication (22.4%), management/judgment (16.0%), and equipment (11.7%). The resident surgeon reported the most errors (52.1%), followed by the circulating nurse (31.9%), the attending surgeon (26.6%), and the anesthesiologist (14.9%). The attending and resident surgeons were most likely to report technical errors (52% and 30.6%, respectively), while anesthesiologists and circulating nurses mostly reported anesthesia errors (36%) and communication errors (50%), respectively. The overlap in reported errors was 20.3%. If this study had used only the surveys completed by the attending surgeon, as in prior studies, 72% of equipment errors, 90% of anesthesia and communication errors, and 100% of nursing errors would have been missed. In addition, it would have been concluded that errors occurred in only 45.2% of cases (rather than 93.5%) and that errors resulting in a delay occurred in 3.2% of cases instead of the 74.2% calculated using data from 4 team members. Compiled results from all team members yielded significant correlations between technical DOCs and prolonged hospital stays and reported and actual delays (p = 0.001 and p = 0.028, respectively). CONCLUSIONS This study is the only of its kind to elicit error reporting from multiple members of the operating team, and it demonstrates error is truly in the eye of the beholder-the types and timing of perioperative errors vary based on whom you ask. The authors estimate that previous studies surveying only the attending physician missed up to 75% of perioperative errors. By finding significant correlations between technical DOCs and prolonged hospital stays and reported and actual delays, this study shows that these surveys provide relevant and useful information for improving clinical practice. Overall, the results of this study emphasize that research on medical error must include input from all members of the operating team; it is only by understanding every perspective that surgical staff can begin to efficiently prevent errors, improve patient care and safety, and decrease delays.
authors.affiliation: School of Medicine, University of North Carolina, Chapel Hill, North Carolina; and.
authors.forename: Suzanne M
authors.initials: SM
authors.lastname: Michalak
authors.affiliation: Department of Neurological Surgery, University of California, San Francisco, California.
authors.forename: John D
authors.initials: JD
authors.lastname: Rolston
authors.affiliation: Department of Neurological Surgery, University of California, San Francisco, California.
authors.forename: Michael T
authors.initials: MT
authors.lastname: Lawton
mesh_terms: D002561:Cerebrovascular Disorders / Q000601:surgery*; D004868:Equipment Failure / Q000706:statistics & numerical data; D005260:Female; D015600:Glasgow Coma Scale; D006801:Humans; D007902:Length of Stay; D008297:Male; D019300:Medical Errors / Q000706:statistics & numerical data*; D008505:Medical Staff, Hospital; D008875:Middle Aged; D019635:Neurosurgical Procedures; D009873:Operating Rooms; D010348:Patient Care Team; D011446:Prospective Studies; D012189:Retrospective Studies; D013997:Time Factors; D016896:Treatment Outcome
keywords: AVM = arteriovenous malformation; DOC = deviation from an optimal course; GCS = Glasgow Coma Scale; LOS = length of stay; cerebrovascular; error; mRS = modified Rankin Scale; multidisciplinary; perioperative; surgery; vascular disorders