|ORIGINAL RESEARCH REPORT
|Year : 2014 | Volume
| Issue : 2 | Page : 47-51
Disclosure of errors and adverse events in surgery: A cross-sectional survey of attitudes and experiences of surgical trainees in Nigeria
Abdulrasheed Ibrahim1, Muhammad B Aminu2, Ibrahim Z Delia2, Sunday A Edaigbini2, Ahmed Mai3, Malachy E Asuku1
1 Department of Surgery; Divisions of Plastic Surgery, Ahmadu Bello University Zaria, Nigeria
2 Department of Surgery and Cardiothoracic Surgery, Ahmadu Bello University Zaria, Nigeria
3 Department of Surgery and General Surgery, Ahmadu Bello University Zaria, Nigeria
|Date of Web Publication||8-Dec-2014|
Department of Surgery, Division of Plastic Surery, Ahmadu Bello University, Zaria
Source of Support: None, Conflict of Interest: None
Background: The patient-surgeon relationship is based on trust, loyalty, and respect. When errors and adverse events occur, they can test the foundation of that relationship with lasting consequences for both the patient and the surgeon. Disclosure of errors and adverse events is a requisite skill in surgical education. Materials and Methods: Surgical trainees' perception of the disclosure of errors and adverse events was evaluated using a questionnaire at the revision course of the West African College of Surgeons in September 2012. The questionnaire addressed three domains: Types of errors that should be disclosed, barriers to disclosure, and experience with disclosure. Results: Nearly all the residents, 60 (95.2%), agreed that adverse events should be disclosed. Most of the respondents, 40 (66.7%), either agreed or strongly agreed that "adverse events and errors in surgery are one of the most serious problems in health care." Only 18 residents (28.5%) either disagreed or strongly disagreed with the statement "It might make me less likely to disclose an error or adverse event to a patient if I think I might get sued." Almost all the residents, 58 (92.1%), have not had a formal training in disclosure of adverse events and errors. Conclusion: The majority of the residents agreed that errors and adverse events should be disclosed. Most of the residents also reported that they have not had a formal training in disclosure. Training residents in disclosure is clearly warranted, as such training will provide them with a valuable skill that they will use throughout their careers.
Keywords: Adverse events, disclosure, errors, surgery, trainees, training
|How to cite this article:|
Ibrahim A, Aminu MB, Delia IZ, Edaigbini SA, Mai A, Asuku ME. Disclosure of errors and adverse events in surgery: A cross-sectional survey of attitudes and experiences of surgical trainees in Nigeria. J Clin Sci 2014;11:47-51
|How to cite this URL:|
Ibrahim A, Aminu MB, Delia IZ, Edaigbini SA, Mai A, Asuku ME. Disclosure of errors and adverse events in surgery: A cross-sectional survey of attitudes and experiences of surgical trainees in Nigeria. J Clin Sci [serial online] 2014 [cited 2019 Dec 12];11:47-51. Available from: http://www.jcsjournal.org/text.asp?2014/11/2/47/146503
| Introduction|| |
The art of surgery is a complex adaptive system that requires the development of a physical craft with cognitive growth. It is given that accuracy, speed, and economy of effort are crucial determinants of surgical skill. It is also well recognized that the need for quick reaction times, team coordination in the context of long hours, and trade-offs between service and safety, have a high potential for error.  Error-free performance is the gold standard expected from all health professionals including surgeons. However, health systems and personnel are not infallible; errors are made, with high human and economic costs. ,,, Studies conducted in various developed countries have reported adverse patient events occurring in 3-30% of hospital admissions with permanent disability or death rates of about 0.4-0.8%. In developing countries, a death rate of 5-10% for major surgery is reported.  Yet, recent studies indicate that disclosure occurs for only about 30% of patients who experience a harmful error. 
Adverse events and errors are difficult to disclose. This difficulty is also seen when most surgeons have to explain to an affected patient or family that his or her efforts to improve health have inadvertently caused harm. , Challenges notwithstanding, error disclosure is a fundamental component of delivering truly patient-centered surgical care.  It is desired by patients, endorsed by ethicists and professional organizations, and increasingly required by regulatory and government bodies. ,,, Indeed, an important indicator of patient safety within a hospital is the documented rate of occurrence of adverse events and its disclosure during the course of inpatient admission.  The consequences of failed disclosure include decreased patient trust and satisfaction, lower patient perceptions of the quality of care; and for the surgeon, a disconnect between actual clinical practice and acceptable professional values. ,
For many trainees in surgery, experience with errors and adverse events comes during actual patient care without the previous benefit of a formal education about the process of disclosure. Like practicing surgeons, most trainees feel responsible, experience a strong emotional reaction, and believe that patients should be told of errors in their care, but there is little known regarding their skills in doing so in practice. ,, To improve our understanding of error disclosure by trainees in surgery, we surveyed residents in teaching hospitals in Nigeria. We deliberately selected this setting because of the formative role teaching hospitals play in the development of the attitudes and practices of trainees.
| Materials and methods|| |
This was a cross-sectional survey conducted among residents at the revision course of the West African College of Surgeons in September 2012. The residents were from 26 accredited tertiary health institutions spread across the six geopolitical zones of Nigeria. Data were collected using a self-administered questionnaire, which was designed after an extensive literature review. ,,, The questionnaire was reviewed by consultants at the Department of Surgery. Participation was completely voluntary, and in order to maintain confidentiality no identifying information was collected. The survey modified slightly the definitions of adverse event, near miss, minor error, and serious error by Gallagher et al.  [Table 1].
The questionnaire was divided into two parts: Demographics and the perception of disclosure of adverse events and errors in surgery. Questions about disclosure of adverse events and errors addressed three domains: Types of errors that should be disclosed, barriers to disclosure, and experience with disclosure. To evaluate participants' attitudes and barriers to disclosure, a four-point Likert scale was used: "Strongly disagree," "disagree," "agree," and "strongly agree." Answer options were "yes" or "no" for questions pertaining to respondents' experience with disclosure. Descriptive statistics and frequency distributions were used to compute all responses.
| Results|| |
The revision course was attended by 123 surgical trainees. The response rate was 51.2% (63/123). Sixty-one male (96.8%) and two female (3.2%) residents participated in the survey. Five (7.9%) residents were in their 1 st year of surgical training, 40 (63.5%) were in their 2 nd and 3 rd years, and 18 (28.6%) were in their 4 th year. The mean age was 36 years (range 25-43 years).
The perceived attitude to disclosure of errors and adverse events is shown in [Table 2]. Nearly all the residents, 60 (95.2%), agreed that adverse events should be disclosed; 38 residents (60.3%) agreed that both near misses and minor errors should be disclosed; while 57 residents (90.5%) either agreed or strongly agreed to the disclosure of serious errors. Most of the respondents, 40 (66.7%), either agreed or strongly agreed that "adverse events and errors in surgery are one of the most serious problems in health care."
|Table 2: Participants' attitudes and perceived barriers to the disclosure of errors and adverse events |
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Despite agreeing that adverse events and errors in surgery should be disclosed, the trainees acknowledged that certain factors might make them less likely to actually disclose [Table 2]. Thirty-seven (58.7%) reported that they might be less likely to disclose if they "think the patient would not understand what I was telling him or her." Other factors the trainees reported that might inhibit disclosure included "If I think I might get assaulted by patients family members/relatives," 51 (80.9%), "if the patient is unaware that the error happened," 30 (47.6%), and "if it would damage a patient's trust in my competence," 29 (46%). Only 18 residents (28.5%) disagreed or strongly disagreed with the statement. "It might make me less likely to disclose an error or adverse event to a patient if I think I might get sued."
Regarding experience with disclosure of adverse events and errors, 44 (69.8%) participants responded that they have been personally involved in a near miss or minor error, and 33 (52.4%) have been personally involved in an adverse event [Table 3]. However, 31 (49.2%) of the residents indicated that they have never disclosed an adverse event or error to a patient, while 52 (82.5%) of the residents acknowledged that their institution did not have a patient safety outcome unit/department/coordinator responsible for the disclosure of errors and adverse events in surgery. Almost all the residents, 58 (92.1%), have not had a formal training in the disclosure of adverse events and errors [Table 3].
|Table 3: Participants experience with disclosure of errors and adverse events |
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| Discussion|| |
The results of this study make important contributions to the limited literature in Nigeria on the perceptions of trainees about the disclosure of adverse events and errors in surgery. Particularly notable was the finding that although an overwhelming majority of the trainees indicated they would likely report adverse events, minor errors, and serious errors, they also acknowledged that certain factors might make them less likely to actually disclose. In this study, the most important obstacles for disclosure were fear of patient's family members' emotional reaction, concern about loss of professional reputation or patient trust, and fear of the malpractice litigation of a lawsuit. Taken together, these results suggest there may be a gap between a positive attitude and actual practices among trainees regarding the reporting of adverse events and errors.  These findings are similar to those by Garbutt et al.,  where the hypothetical disclosure of minor and serious errors among residents were found to be 90% and 99%, respectively. Likewise, in the study by Kaldjian et al.,  the figures for minor and major error disclosures were 97% and 93%, respectively. In practice, however, Hobgood et al.,  showed that only 28% of residents had disclosed their most significant error with the patients or the patients' family.  In addition, several studies also suggest that shame, embarrassment, social and cultural differences of our patients, and the lack of a support system for physicians following errors and adverse events may preclude complete and effective disclosures. ,,,
Given the difficulty and importance of disclosing adverse events and errors to patients, there is a need to learn more about the practice of error disclosure and the diverse factors that may facilitate or impede it. This is desirable given the tension between the transparency promoted by the need for patient safety and the silence induced by the malpractice system.  Questions about legal liability regularly arise in discussions about error reporting because of concerns that reported information may be discoverable in a malpractice proceeding. In response to such concerns, most authors recommend that error reporting systems be confidential.  Furthermore, there are compelling reasons for a legislation to protect surgeons under the umbrella of peer review by making the reporting and discussion of errors privileged. Such legislation can reassure wary surgeons that their conscientious efforts to improve the quality of health care will not be used against them. 
In this study, the majority of the residents reported personal experience with errors and adverse events in surgery. Indeed encounters with errors and adverse events begin early in training. Stroud et al.  observed that many residents, across different specialties, report having made a serious error during their training. Like practicing surgeons, most residents feel responsible for errors and experience a strong emotional reaction to errors.  The majority of the residents, 52 (82.5%), also reported that their institution did not have a patient safety outcome unit responsible for disclosure and 58 (92.1%) of the residents have not had a formal training in disclosure. This is especially disturbing given the surgical burden and challenges in a context of scarce resources and weak infrastructure in a low-resource setting.
Understanding when, how, and why errors and adverse events occur is crucial to improve surgical care. It will also facilitate the adoption of the most effective and efficient corrective actions.  Experience alone is not sufficient, thus the early development of skills and comfort in error disclosure will provide a valuable asset throughout a resident's career. , All hospitals and surgical departments should establish error disclosure units saddled with the responsibility of full disclosure. The unit will develop a written institutional protocol including an explicit statement that there was an error, details of what went wrong, and why the adverse event or error occurred. An anonymous reporting system should be encouraged to collect and analyze information about adverse events and errors, emphasizing relevant information about both the processes of care and the consequences of those actions. 
Disclosures are emotionally charged conversations that require advanced communication skills.  Numerous toolkits in error disclosure have been developed to improve disclosure culture and implementation. These include just-in-time disclosure coaching, role modeling by senior surgeons, skills training, simulation, and support after adverse events and errors. , All residents should be aware of the disclosure support resources that their institution or malpractice insurer offers and ensure that they take full advantage of these supports before and after disclosure conversations with patients.  For patients, complete disclosure after an adverse event or error, even a minor one, includes acknowledgment that an event has happened and an explanation of how the event impacts the patient's health and how that impact will be mitigated. Moreover, the disclosure should explicitly state why the error happened and how recurrences will be prevented. Patients not only desire information, they also want emotional support, including an empathic apology.  Finally, institutions should consider ways to promote patient-centered ethical values that may motivate surgeons to report errors especially in teaching hospitals where role models play a vital part in the formation of trainees' attitudes and practices. Such values are rightly seen as part of medical professionalism and reflect a commitment not merely to good systems but as an integral component of a broader quality improvement in surgical care. 
This study has some limitations. The sample size is relatively small and may be biased toward the viewpoints of only residents who support disclosure of errors as an integral part of a surgeon's duty. A second weakness is the nature of the subject population-surgical trainees. There is a lack of perspective of the patients. It will be important to study patient experiences with error disclosure as greater numbers of residents receive training. ,, Further work is required to evaluate the effectiveness of any disclosure training, including longitudinal follow-up to determine whether the learned behaviors endure and whether education changes long-term practice and attitudes toward disclosure.
| Conclusion|| |
Our study demonstrates that there is a need to encourage, guide, and support disclosure among surgical trainees. The majority of the residents agreed that errors and adverse events should be disclosed. The most important obstacles for disclosure were fear of family members' emotional reactions, concern about loss of patient trust, and fear of malpractice litigation. Most of the residents also reported that they have not had a formal training in disclosure. Knowledge about how to report errors is essential, especially in a training environment in which trainees need to observe a connection between institutional messages about the importance of reporting and clinical practices that make such messages credible.
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[Table 1], [Table 2], [Table 3]