Study finds human error to blame for over half the adverse events patients suffer during surgery. Should doctors apologize for their errors? It’s all about the timing.

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The News:

More than half of adverse events occurring during surgical procedures resulted from human error, and just over half of these errors were cognitive in nature, according to a quality improvement study in JAMA Network Open.

The researchers developed a tool for classifying human error and applied the tool on a weekly basis at three affiliate hospitals concurrently: a level I municipal trauma center, a quaternary care university hospital, and a US Veterans Administration hospital. They aimed to better understand behavioral drivers by examining both individuals’ and teams’ errors that led to adverse events.

“These findings could provide a basis for new approaches to cognitive training for surgeons and other healthcare practitioners to enhance the safety of surgical care delivery, approaches similar to those used in other high-risk industries, such as the aerospace industry,” write James W. Suliburk, MD, of Baylor College of Medicine in Houston, TX, and colleagues.

The investigators developed and implemented a new tool that classified human performance deficiencies (HPDs) into five cognitive, technical, or team dynamic functions-related categories. The categories included execution; planning or problem solving; communication; teamwork; and rules violation.

Each week, a morbidity and mortality conference at the hospital brought together all attending faculty, residents, and surgical trainees to discuss and categorize the previous week’s adverse events from general surgery, acute care surgery, surgical oncology, cardiothoracic surgery, vascular surgery, and abdominal transplantation services. Before these meetings began, surgeons received training in using the HPD classifier tool.

Among 5,365 patients, 3.4% (182 patients) experienced an adverse event during a surgical operation. Adverse events occurred in another six patients during nonoperative treatment. Human error was responsible for more than half of these adverse events (56.4%). Most of the errors (51%) were related to execution whereas 29.3% were related to planning or problem solving, 12.8% to communication, 4.8% to teamwork, and 3.2% to rules violation.

Most of the human errors occurred during the surgery itself (54.8%) whereas 8% occurred preoperatively and 26.6% postoperatively. Among the adverse events arising from human performance deficiencies, 51.6% of the errors were cognitive, “most commonly presented as cognitive errors in execution of care or in case planning or problem solving,” the authors report.

Common cognitive errors in execution included lack of attention, memory lapses, or lack of recognition of a problem, which together comprised nearly one third (31.8%) of the cognitive errors. Another 19.8% resulted from cognitive bias in care planning or problem solving.

“Given that we and others report a current surgical adverse event rate of nearly 5%, our data suggest that more than 400,000 potentially preventable adverse events associated with HPDs occur among the nearly 17 million inpatient and ambulatory operative procedures performed in the US annually,” the authors write. (Ref: Medscape)

Steve’s Take:

Some ten years ago I co-founded a reference resource for physicians called The Physician’s Index for Ethics in Medicine. I have been privileged to sit in on semi-annual meetings of our distinguished editorial advisory board (EAB) and learned just how often physicians and other healthcare providers are confronted with challenging ethical dilemmas. It’s in these discussions such as these where the issue of medical errors crops up time after time.

This latest study reported in JAMA Network Open says over half of the medical errors during surgery are attributed to human error. As a lawyer, the first thing that occurred to me was how large a pool of potential medical malpractice cases there must be as a result of doctor error.

And this thought led me back to a discussion of our EAB about medical errors and the issue of if and when a physician might apologize for committing an error in the course of medical treatment of a patient. This question touches on what should be the key point: what actually is a medical error? A delayed diagnosis is only an error if one supposes that perfect knowledge in retrospect is the standard. Accidentally nicking an artery is only an error if we say that perfect outcomes are the standard.

I agree with Medscape, which last month said there needs to be a distinction between real-world risks and knowledge, rather than “the use of some utopian standard of perfection as the [rule]. It seems the notion now in effect is that one is making an error if you don’t make the absolute [correct] diagnosis in the first appointment. As to surgeons, any outcome short of perfect is now called ‘error.’…Statements that hundreds of thousands are killed annually by medical error base their definition of error on anything not done perfectly in zero time expired.”

What is medical malpractice?

Worldwide, people rely on doctors and hospitals to make them well when they are injured or get sick. Unfortunately, doctors and other medical staff occasionally make mistakes which can have serious consequences for patients. When these mistakes cause an injury and are made because a medical professional deviated from accepted norms of practices, it’s referred to as medical malpractice.

According to a 2016 study in BMJ, medical errors might be the third leading cause of death in the US. The study suggests that medical errors may kill more people than emphysema and bronchitis, which means that only heart disease and cancer are deadlier. The doctors who conducted the study estimate that there are at least 251,454 deaths due to medical errors every year in the US. Even more alarming is their contention that the number could actually be much higher because home and nursing-home deaths aren’t counted in the total.

Clearly, medical error is a very serious problem. However not all medical errors rise to the level of medical malpractice. Still, these numbers point to an alarmingly high rate of negative medical outcomes.

All of which raises the curious question: Should physicians rethink saying “I’m sorry” after a medical error? If patients will sue and perhaps win anyway, what good does it do to apologize? “The ‘apology folks’ tell us that we can go in and tell a person that we made a mistake that killed their father, and the family will forgive us.

But many physicians who believe in the laws end up regretting it,” says Victor Cotton, MD, an internist and attorney who is president of Law and Medicine, a company that provides continuing medical education on medico-legal issues based in Hershey, PA. Some patients and families may, in fact, forgive the doctor who apologizes, but they are not willing to forget. A 2009 study showed that patients and families do indeed come away with a higher opinion of these doctors, but they will still sue them.

Thirty-nine states have passed laws trying to protect doctors from malpractice litigation if they apologize for a medical error. However, a new study says these laws do not protect doctors, and in many cases, the laws even heighten their risks of a lawsuit. Of the 39 states with apology laws, just seven protect an admission of error. The rest have “partial apology” laws that only cover expressions of sympathy–for example, “I’m sorry that happened to you”–but not an outright apology.

Physicians’ views on apologizing

Even when physicians seriously considered apologizing in the 2000s, they were always very wary of how much to tell patients about errors. In addition to fear of lawsuits, they worried about the shame of having to recognize their error, and they do not know how to go about apologizing, according to one report.

Studies also have shown that many doctors do not want to acknowledge the full extent of an error to patients. For example, when asked how they would portray a delayed diagnosis of breast cancer and a delayed response to symptoms due to poor coordination of care, more than 70% of primary care physicians said they would provide “only a limited or no apology, limited or no explanation, and limited or no information about the cause,” according to a 2016 study.

“If you commit a moral wrong against someone, you should apologize,” Cotton says. But a surgeon who “inadvertently injures a nerve during a complex procedure has not committed a moral wrong. The physician needs to give his best effort.”

Cotton contends that expecting doctors to confess everything to patients is unrealistic.

“The concept of saying I’m sorry was invented by risk officers at hospitals and malpractice insurance carriers, not doctors,” he says. “Should physicians have to apologize each time they make a judgment call?”

Bottom Line:

Putting aside for the moment the question of the dollars at stake when human error results in injury, Dr. James Marshall, in a comment upon the aforementioned Medscape article, says it seems there are two versions of this ethical dilemma. “

The liberal view of if I do something that is ‘right’ only good will follow, so apologize because it’s the ‘right’ thing to do–consequences be damned–and the hard reality plaintiff lawyers bring where clearing your conscience is now Exhibit A in your malpractice trial.”

Another comment by a surgeon asserts that, “Lawyers should be sued for malpractice every time they lose a case if they want to hold us to similar standards. After all, every case is potentially winnable, but death is inevitable. If you make a mistake, learn from it, grow from it, but don’t try to clean your conscience with an apology.”

I’ll conclude with the practical comment from another surgeon that hits the nail on the head:

“[Saying] I’m sorry can’t [compete] with a check with 6 zeros on it. That is the world we live in today. …None of us got into this to hurt people, so saying sorry is superfluous and maybe even shallow. If you are truly sorry and can’t move on without an apology, then wait until after the malpractice suit to apologize (if you still think one is appropriate).”

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