Surgical errors remain a challenge; burnout cited as primary cause

December 3, 2009

Despite a national focus on reducing surgical errors, surgery-related adverse events continue to occur both inside and outside the operating room, according to a recent analysis of events at Veterans Health Administration Medical Centers.

Despite a national focus on reducing surgical errors, surgery-related adverse events continue to occur both inside and outside the operating room, according to a recent analysis of events at Veterans Health Administration Medical Centers.

First author Julia Neily, RN, MPH, of the VHA in White River Junction, VT, and colleagues reviewed reported surgical adverse events occurring at 130 VHA facilities between January 2001 and June 2006. Events were categorized by location, specialty departments, body segments, severity, and several other characteristics.

Overall, the researchers reviewed 342 reported events, including 212 adverse events and 130 close calls. Of the adverse events, 108 (50.9%) occurred in an operating room and 104 (49.1%) occurred elsewhere.

"When examining adverse events only, ophthalmology and invasive radiology were the specialties associated with the most reports (45 [21.2%] each)," the authors wrote. "The most common root cause of events was communication."

Urology ranked fourth among the specialties studied, with 23 adverse events reported. Of these, the most common error was operating on the wrong side (12 cases).

Results of the analysis appeared in the Archives of Surgery (2009; 144:1028-34).

In related news, major medical errors self-reported by American surgeons are strongly related to both burnout and depression, according to results of a study published online in Annals of Surgery (Nov. 19, 2009).

The study, led by researchers from the Mayo Clinic, Rochester, MN, included collaborators from Johns Hopkins University, Baltimore, and the American College of Surgeons. Nearly 9% of U.S. surgeons responding to the confidential survey said they made a major error in the 3 months prior to being surveyed. More than 70% attributed the error to themselves rather than a systemic or organizational cause. Results showed that surgeon burnout was related to errors, as was surgeons’ "mental quality of life," including depression.

"These results suggest that a surgeon’s personal mental health, including burnout, may have an effect on quality of care," said lead author Tait Shanafelt, MD, of the Mayo Clinic. "Our aim is to encourage more research to find ways to reduce distress among surgeons and to provide better support when errors occur."