Skip to main navigation menu Skip to main content Skip to site footer

Original article

Vol. 143 No. 3940 (2013)

Reasons for the persistence of adverse events in the era of safer surgery – a qualitative approach

  • Reto Kaderli
  • Julia C. Seelandt
  • Melika Umer
  • Franziska Tschan
  • Adrian P. Businger
DOI
https://doi.org/10.4414/smw.2013.13882
Cite this as:
Swiss Med Wkly. 2013;143:w13882
Published
22.09.2013

Abstract

OBJECTIVE: We sought to evaluate potential reasons given by board-certified doctors for the persistence of adverse events despite efforts to improve patient safety in Switzerland.

SUMMARY BACKGROUND DATA: In recent years, substantial efforts have been made to improve patient safety by introducing surgical safety checklists to standardise surgeries and team procedures. Still, a high number of adverse events remain.

METHODS: Clinic directors in operative medicine in Switzerland were asked to answer two questions concerning the reasons for persistence of adverse events, and the advantages and disadvantages of introducing and implementing surgical safety checklists. Of 799 clinic directors, the arguments of 237 (29.7%) were content-analysed using Mayring’s content analysis method, resulting in 12 different categories.

RESULTS: Potential reasons for the persistence of adverse events were mainly seen as being related to the “individual” (126/237, 53.2%), but directors of high-volume clinics identified factors related to the “group and interactions” significantly more often as a reason (60.2% vs 40.2%; p = 0.003). Surgical safety checklists were thought to have positive effects on the “organisational level” (47/237, 19.8%), the “team level” (37/237, 15.6%) and the “patient level” (40/237, 16.9%), with a “lack of willingness to implement checklists” as the main disadvantage (34/237, 14.3%).

CONCLUSION: This qualitative study revealed the individual as the main player in the persistence of adverse events. Working conditions should be optimised to minimise interface problems in the case of cross-covering of patients, to assure support for students, residents and interns, and to reduce strain. Checklists are helpful on an “organisational level” (e.g., financial benefits, quality assurance) and to clarify responsibilities.

References

  1. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building a Safer Health System. Washington DC: National Academies Press; 2000.
  2. de Vries EN, Ramrattan MA, Smorenburg SM, Gouma DJ, Boermeester MA. The incidence and nature of in-hospital adverse events: a systematic review. Qual Saf Health Care. 2008;17(3):216–23.
  3. Patient Safety Foundation. Patientensicherheit geht uns alle an – Zahlen und Fakten. 2011. Available at: http://www.patientensicherheit.ch/de/publikationen/Pr-sentationen.html. Accessed January 01, 2013.
  4. Zegers M, de Bruijne MC, de Keizer B, Merten H, Groenewegen PP, van der Wal G, et al. The incidence, root-causes, and outcomes of adverse events in surgical units: implication for potential prevention strategies. Patient Saf Surg. 2011;5:13.
  5. World Health Organization. Patient safety. 2012. Available at: http://www.who.int/patientsafety/en. Accessed January 01, 2013.
  6. Runciman WB, Baker GR, Michel P, Dovey S, Lilford RJ, Jensen N, et al.; Methods & Measures Working Group of the World Health Organization World Alliance for Patient Safety. Tracing the foundations of a conceptual framework for a patient safety ontology. Qual Saf Health Care. 2010;19(6):e56.
  7. Donaldson SL. An international language for patient safety: Global progress in patient safety requires classification of key concepts. Int J Qual Health Care. 2009;21(1):1.
  8. McCulloch P, Mishra A, Handa A, Dale T, Hirst G, Catchpole K. The effects of aviation-style non-technical skills training on technical performance and outcome in the operating theatre. Qual Saf Health Care. 2009;18(2):109–15.
  9. Gurusamy K, Aggarwal R, Palanivelu L, Davidson BR. Systematic review of randomized controlled trials on the effectiveness of virtual reality training for laparoscopic surgery. Br J Surg. 2008; 95(9):1088–97.
  10. Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, et al.; Safe Surgery Saves Lives Study Group. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360(5):491–9.
  11. Lingard L, Espin S, Rubin B, Whyte S, Colmenares M, Baker GR, et al. Getting teams to talk: development and pilot implementation of a checklist to promote interprofessional communication in the OR. Qual Saf Health Care. 2005;14(5):340–6.
  12. Lingard L, Regehr G, Orser B, Reznick R, Baker GR, Doran D, et al. Evaluation of a preoperative checklist and team briefing among surgeons, nurses, and anesthesiologists to reduce failures in communication. Arch Surg 2008;143(1):12–7; discussion 18.
  13. Kaderli R, Cecini Hertig R, Laffer U, Businger AP. Surgical Safety Checklists in Operative Medicine in Switzerland. Arch Clin Exp Surg. 2012;1(3):158–67.
  14. Suñol R, Vallejo P, Groene O, Escaramis G, Thompson A, Kutryba B, et al. Implementation of patient safety strategies in European hospitals. Qual Saf Health Care. 2009;18(Suppl 1):i57–i61.
  15. Rose N, Ortner MA, Meyenberger C, Blum AL. Die Patientensicherheit in der Schweiz, Resultate einer Expertenbefragung. SÄZ. 2009;90:48.
  16. Rose N, Hess U. Meldung von Near Misses im Krankenhaus – Klinisches Risikomanagement in der Onkologie. Der Onkologe. 2008;14:721–6.
  17. Swiss Medical Association (FMH). Weiterbildungsstätten – qualitätsorientierte Kriterien. 2012. Available at: http://www.fmh.ch/bildung-siwf/weiterbildung_allgemein/weiterbildungsstaetten.html#. Accessed January 01, 2013.
  18. Swiss college of surgeons. Foederatio medicorum chirurgicorum helvetica (fmCh). 2010. Available at: http://www.fmch.ch/. Accessed January 01, 2013.
  19. Mayring P. Qualitative Inhaltsanalyse. Grundlagen und Techniken. 7th edition. Weinheim, Beltz: Deutscher Studienverlag; 2000:53–63.
  20. Amalberti R, Auroy Y, Berwick D, Barach P. Five system barriers to achieve ultrasafe health care. Ann Intern Med 2005;142(9):756–64.
  21. Gaba DM, Howard SK. Patient safety: fatigue among clinicians and the safety of patients. N Engl J Med. 2002;347(16):1249–55.
  22. Gander PH, Merry A, Millar MM, Weller J. Hours of work and fatigue-related error: a survey of New Zealand anaesthetists. Anaesth Intensive Care. 2000;28(2):178–83.
  23. Firth-Cozens J, Greenhalgh J. Doctors' perceptions of the links between stress and lowered clinical care. Soc Sci Med. 1997;44(7):1017–22.
  24. Kaderli R, Businger A, Oesch A, Stefenelli U, Laffer U. Morbidity in surgery: impact of the 50-hour work-week limitation in Switzerland. Swiss Med Wkly 2012; 142:0. doi: 10.4414/smw.2012.13506.
  25. Businger AP, Laffer U, Kaderli R. Resident work hour restrictions do not improve patient safety in surgery: a critical appraisal based on 7 years of experience in Switzerland. Patient Saf Surg. 2012;6(1):17. doi: 10.1186/1754-9493-6-17.
  26. Laine C, Goldman L, Soukup JR, Hayes JG. The impact of a regulation restricting medical house staff working hours on the quality of patient care. JAMA. 1993;269(3):374–8.
  27. Petersen LA, Brennan TA, O’Neil AC, Cook EF, Lee TH. Does housestaff discontinuity of care increase the risk for preventable adverse events? Ann Intern Med. 1994;121(11):866–72.
  28. Baker GR, Norton PG, Flintoft V, Blais R, Brown A, Cox J, et al. The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. CMAJ. 2004;170(11):1678–86.
  29. Gawande AA, Zinner MJ, Studdert DM, Brennan TA. Analysis of errors reported by surgeons at three teaching hospitals. Surgery. 2003;133(6):614–21.
  30. Gawande AA, Studdert DM, Orav EJ, Brennan TA, Zinner MJ. Risk factors for retained instruments and sponges after surgery. N Engl J Med. 2003;348(3):229–35.
  31. de Vries EN, Prins HA, Crolla RM, den Outer AJ, van Andel G, van Helden SH, et al.; SURPASS Collaborative Group. Effect of a comprehensive surgical safety system on patient outcomes. N Engl J Med. 2010;363(20):1928–37.
  32. Neily J, Mills PD, Young-Xu Y, Carney BT, West P, Berger DH, et al. Association between implementation of a medical team training program and surgical mortality. JAMA. 2010;304(15):1693–1700.
  33. Verdaasdonk EG, Stassen LP, Widhiasmara PP, Dankelman J. Requirements for the design and implementation of checklists for surgical processes. Surg Endosc. 2009;23(4):715–26.
  34. Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, et al.; Safe Surgery Saves Lives Study Group. Changes in safety attitude and relationship to decreased postoperative morbidity and mortality following implementation of a checklist-based surgical safety intervention. BMJ Qual Saf. 2011;20(1):102–7.
  35. Lingard L, Whyte S, Espin S, Baker GR, Orser B, Doran D. Towards safer interprofessional communication: constructing a model of “utility” from preoperative team briefings. J Interprof Care. 2006;20(5):471–83.
  36. Vats A, Vincent CA, Nagpal K, Davies RW, Darzi A, Moorthy K. Practical challenges of introducing WHO surgical checklist: UK pilot experience. BMJ. 2010;340:b5433. doi: 10.1136/bmj.b5433.
  37. Van Vegten A, Tanner M, Ammann C, Giovanoli P, Giuliani F, Kiss H, et al. ChecklistenKULTur: Ein Plädoyer für den sinnvollen Einsatz von Checklisten. SÄZ. 2011;92(40):1547–50.
  38. Degani A, Wiener EL. Cockpit Checklists: Concept, design and use. Available at: http://ti.arc.nasa.gov/m/profile/adegani/Cockpit%20Checklists.pdf. Accessed January 01, 2013.
  39. Clavijo-Alvarez JA, Pannucci CJ, Oppenheimer AJ, Wilkins EG, Rubin JP. Prevention of venous thromboembolism in body contouring surgery: A national survey of 596 ASPS surgeons. Ann Plast Surg. 2001;66(3):228–232.
  40. Jackson I, Bobbin M, Jordan M, Baker S. A survey of women urology residents regarding career choice and practice challenges. J Womens Health. (Larchmt) 2009;18(11):1867–72.
  41. Leece P, Bhandari M, Sprague S, Swiontkowski MF, Schemitsch EH, Tornetta P, et al. Internet versus mailed questionnaires: a controlled comparison (2). J Med Internet Res. 2004;6(4):e39.
  42. Brehaut JC, Graham ID, Visentin L, Stiell IG. Print format and sender recognition were related to survey completion rate. J Clin Epidemiol. 2006;59:635–41.