Awareness regarding surgical errors, its occurrence and their coping strategies among the surgeons of BPKIHS

Abstract

Introduction:

Surgical errors are a significant concern in medical practice, particularly in teaching institutions where trainees are frequently involved in patient care. These errors, which include deviations from standard surgical procedures, can lead to adverse patient outcomes in one hand whereas emotional distress among surgeons on the other hand as well. Understanding the prevalence, types, and coping mechanisms for surgical errors is essential for developing effective strategies to minimize their occurrence and impact.

Results:

This cross-sectional study involved 134 surgeons from various specialties at B.P. Koirala Institute of Health Sciences (BPKIHS), with 50.7% being resident doctors. A total of 79.1% admitted to committing surgical errors during their careers at some points of time. All errors, self-accepted by surgeons enrolled in the study were minor ones. Frequently reported errors included inappropriate incision (77.5%), anesthesia titration errors (75.7%), and unintentional organ/tissue injury (69.2%). Female surgeons were more likely to self-report errors than male surgeons.

All errors had occurred during the early phase of surgical training. Surgeons attributed errors to systemic and personal factors, including insufficient staffing, fatigue, and poor communication. Common coping strategies included escape and self-instruction, though not all were effective in mitigating stress.

Conclusion:

The high incidence of minor errors seems to be acceptable part of learning in teaching institute where trainees are frequently involved in patient care. None of the error was major because in teaching institute like ours, the trainees are at frontline in patient care but are always under supervision of senior clinicians. All errors have occurred during the early phase of surgical training. There is need of targeted interventions, including training, support systems, and institutional reforms to reduce surgical errors and improve surgeon well-being.

Introduction

At its most fundamental level, an error occurs when an activity shifts from normal and usual to abnormal in some way^[1,2]. A surgeon will make an error in the operating room at some point during their training or professional career. Errors happen regularly; according to a nationwide survey, approximately 9% of surgeons in the United States have made medical errors at some point^[3]. Medication errors (e.g., wrong medication, wrong dose, inability to notice an allergy), patient misidentification and diagnosis errors or delays are all examples of medical errors.^[4–6] In addition to the faults that any physician can make, surgeons can also make mistakes such as performing procedures on the wrong place or with the wrong method^[7,8]. Surgical errors can be significant, with serious repercussions for the patient, the surgeon, and the institution. Physicians have been termed the “second victim” of medical error^[9]. Itis possible that the chance of admitting errors to patients varies by profession, with some research suggesting that surgeons are less likely to do so than those in other specialties^[10]. Physician burnout and depression may compromise the quality of treatment provided by physicians and contribute to medical errors^[11,12]. Critical thinking time is limited in an emergency circumstance. It is often impossible to postpone decisions, yet every decision made under pressure increases the risk of error, just as making no decision at all may result in a serious outcome. The problem is not bad people in healthcare; it is that good people are working in bad systems that need to be made safer^[13].

There are two types of coping strategies: postoperative strategies for learning from mistakes and dealing with mental anguish (e.g., discussing the error with peers) and intraoperative strategies for correcting mistakes and moving forward (e.g., taking a step back to reevaluate or making ergonomic adjustments)^[3]. Surgeons’ postoperative coping mechanisms have been studied to some extent. Surgeons acknowledged discussing the problems, analyzing the episodes, and reasoning in a small set of interviews studying how surgical error affects them. Preoperative and intraoperative coping tactics are heterogeneous, with things ranging from “planning the operation” and “team briefing” to “self-talk” and “ergonomic modifications.”^[3]

No research has been done regarding the coping strategies for medical errors among surgeons in Nepal. Hence, study aims to find out the coping strategies used by surgeons in our settings and analyze its effectiveness. This cross-sectional study has been reported in line with the STROCSS guidelines^[14].

Methods

The study will include the registered surgeons of Nepal.

Types of study design: Pro-forma Based Study(printed/google form). We have used the questionnaire from the research of Sewal RK et al^[15] with some modifications after consent from the author. The study included surgeons from various specialties such as general surgery, orthopedic, ENT, ophthalmology, urosurgery, pediatric surgery, cardiothoracic& vascular surgery and neurosurgery branches.

Study population: Board-certified surgeons and specialists and residents were included.

Criteria for sample selection:

1. Inclusion criteria: Board-certified surgeons and residents were included.

2. Exclusion criteria:

   • Refusal to consent for participation.
   • Incompletely filled pro-forma

Setting: BPKIHS

Study period: The duration of the study was 28 days

Ethical clearance: The ethical clearance was obtained from the Institutional Review Committee (IRC),BPKIHS.

Conflict of interest: None

Sampling technique: Snow ball technique

Sample size: Based on the research of Shanafelt et al^[16], we are taking prevalence rate of surgical errors to be 9%. By using the formula, n = z²pq/d² = [1.96² × 0.09 × 0.91]/0.05² = 125.85. On rounding off, it comes to sample size of 126, where, n = Z = 1.96 (z score of 95% CI).

P = prevalence of awareness

Q = 1-p

D = margin of error

Methods

Questionnaire: A self-administered structured questionnaire in hard copy was given to the surgeons to fill in as depicted in Fig 1.

Outcome measures

• Errors occurrence among the surgeons of BPKIHS.

• Correlation of errors with work experience and prior exposure to case.

• Distribution of coping strategies used in reducing stress following surgical errors.

Data management and statistical analysis

Statistical analysis

1. Data handling: Data were entered in Microsoft Excel 2016 (Microsoft Corporation, Redmond, Washington, USA) and statistical analysis was done using Statistical Package for the Social Sciences 11.5 version (Chicago, Inc.).

2. Coding: Alpha numerical code was used

3. Monitoring: Data were entered after every day of work and supervised by the guide.

4. Statistical analysis:

HIGHLIGHTS

• Prevalence of errors: The study found that 79.1% of surgeons at B.P. Koirala Institute of Health Sciences admitted to having committed surgical errors, with female surgeons more likely to report these errors than male surgeons.

• Types of errors: Major surgical errors reported include unnecessary surgeries (77.5%), anesthesia mistakes (75.7%), and leaving foreign bodies inside patients (70.8%).

• Coping strategies: Surgeons predominantly employed coping strategies such as escape (91.5%), positive self-instructions (77.4%), and minimization (69.8%) to manage the stress associated with surgical errors.

• Effectiveness of coping mechanisms: The study found that common coping strategies like positive self-instructions, escape, and resignation were largely ineffective in significantly reducing stress among surgeons.

• Systemic and individual factors: The research emphasizes the importance of addressing both individual coping mechanisms and systemic support to effectively manage and reduce the incidence of surgical errors and their emotional impact on surgeons.

For descriptive analysis percentage, ratio, mean, standard deviation (SD) and median were calculated along with graphical and tabular presentations.

For inferential statistics, bivariate analysis was done using χ2 test, odds ratio and a 95% confidence interval. Univariate and multivariate logistic regression was done to determine the percentage of errors in surgeons of BPKIHS. Odds ratios (OR) significance was determined by the Wald Chi-squared test, and predictors with P <0.20 for subsequent multivariate analysis.

The amount of decrease in the errors after the coping strategies was calculated and P <0.05 was considered statistically significant.

Ethics

The procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation and with the Helsinki Declaration of 1975, as revised in 2000. Evidence for approval by a local Ethics Committee can be made available supplied by the authors on demand.

Results

Total of 134 surgeons working at BPKIHS were given a set of preprinted questionnaires to fill regarding the Awareness of surgical errors, its occurrence, and their coping strategies. Out of 134 surgeons, 75.4% (101) were male and 24.6% (33) were female (Fig. 2). Regarding the work experience, we found that 9.7% had 1 year of experience, 24.6% of them had at least 2 years of experience, 23.1% had 3 years of experience, 16.4% had 4 years of experience, 16.4% had 5 years of experience, 4.5% had 6 years of experience, 1.5% had 7 years of experience, 2.2% had 8 years of experience and 1.4% had more than 10 years of experience (Fig. 3).

Figure 1.

Flow chart showing how the study was conducted.

Figure 2.

Showing the demographic of male (75.4%) and female (24.6%).

Figure 3.

Histogram showing percentages of experience in years.

79.1% of the surgeons self-admitted that they had done surgical errors at some point in their time of practice and all of them were minor errors. In this study an error was considered major if it produced a constant threat to survival of patient. Furthermore, when we analyzed the surgical errors with gender, we found that female surgeons committed more errors than male surgeons with P value of 0.003. This may be because female surgeons are more likely to be open about the errors committed than the male surgeons and there is a less population of female surgeons in our country. When we compared the work experience in field with the error’s occurrence, around 60% of surgeons included in the study have work experience of <4 yrs (post-MBBS). Among the surgeons with 1 year, 5 years, and 10 years of experience; 30.8%, 81.8%, and 100% were aware of surgical errors respectively.

On the other hand, among the surgeons with 1 year, 5 years, and 10 years of experience; 23.1%, 81.8%, and 100% were aware of any form of coping strategies respectively shown in Fig. 4.

Figure 5.

Graph showing reason for errors.

Figure 6.

Percentage of different coping strategies used.

Figure 4.

Amount of coping strategy awareness in surgeons with different experience.

Out of the surgeons who committed surgical errors, 87.1% of the surgeons informed to the higher authority regarding the surgical errors while 11.9% did not inform and 1% abstained from commenting. 89.6% of the surgeons who committed surgical errors believed that the institution should form an independent body for reporting of the surgical errors.

None of them accepted that they have committed a major error till date of data entry whereas 79.1% admitted that they have committed minor errors at some point of time. The self-accepted minor errors were inappropriate Incision (in 77.5% cases), anesthesia mistake (in 75.7% cases), and injury to organs or tissues unintentionally (in 69.2% cases).The total added percentages cross 100% because more than 1 type of errors could have been committed by the same surgeon at different points of time.

When the surgeons were asked about the causes of the surgical errors, surgeons believed following reasons were responsible: prescription errors – 77.4%, busy schedule – 75.2%, lack of communication – 71.7%, insufficient staff – 60.4%, incompetence of surgeon – 56.6%, and fatigue – 35.8%. More than one reason was reported to be responsible for the occurrence of surgical error as is depicted in Fig. 5.

After committing surgical errors, surgeons used following coping strategies to minimize the stress following surgical errors:

Escape (leaving the surgery) by 91.5% of surgeons, positive self-instructions (giving positive consolation to oneself) by 77.4% of surgeons, minimization (69.8%), avoidance (69.8%), self-blame (67%), distraction (engaging in other activities to distract oneself) 65.1%, substitute gratification (seeking positive response from other conditions) 64.2%, rumination (deep thinking about such errors occurring in the future) 61.3%, reaction control (suppressing emotional outbursts) 51.9%, situation control 50.9%, and resignation 0.0%. as is depicted in Fig. 6.

Discussion

During surgical training and professional practice, it is almost inevitable that surgeons will encounter instances of error within the operating room (OR). Fundamentally, an error can be described as a deviation from the expected or routine execution of a task, resulting in an abnormal or unintended outcome. Even momentary lapses or brief distractions may have significant implications for both patient safety and surgeon well-being. Such incidents are not uncommon; for example, a national survey conducted in the United States reported that approximately 9% of surgeons admitted to committing a major medical error within the three months preceding the survey^[16]. In our study, 79.1% of surgeons practicing at BPKIHS acknowledged having made some form of MINOR errors at some point during their surgical careers and none accepted to have committed any major errors. However, direct comparison between these two studies is not possible, as the former examined recent MAJOR error incidence over a three-month timeframe, while the latter reflects self-accepted cumulative experience across the surgeon’s entire practice duration.

Investigating how surgeons respond to and manage errors is essential for two primary reasons. Firstly, the experience of committing an error is closely linked with increased surgeon burnout and reduced mental quality of life, underscoring the need for supportive strategies to mitigate psychological distress. Secondly, a surgeon’s capacity to respond effectively to an error plays a critical role in reducing the likelihood of adverse patient outcomes, including morbidity and mortality.

Coping mechanisms for surgical errors can be broadly classified into intraoperative and postoperative strategies. Intraoperative strategies involve immediate actions to address the error – such as pausing for reassessment or making ergonomic adjustments – while postoperative strategies include reflective processes, discussions with colleagues, and other methods aimed at managing emotional distress and extracting lessons from the experience. Although several qualitative studies have explored aspects of postoperative coping – documenting how surgeons rationalize complications and share experiences – there remains a need for further research into evidence-based approaches for supporting surgeons after errors.

Existing literature, predominantly qualitative in nature, has revealed that surgeons often perceive adverse events as rare and highly individualized experiences, frequently accompanied by feelings of isolation^[3]. However, there is a noticeable gap in the literature regarding the prevalence and types of postoperative coping mechanisms employed across diverse surgical populations.

A study by D’Angelo et al reported that female surgeons tended to focus more on self-soothing strategies, whereas male surgeons emphasized ergonomic modifications to reduce the risk of error^[3]. In contrast, our findings indicated that escape-oriented coping was the most commonly employed strategy by both genders – used by 97% of female and 91.1% of male participants – while reaction control was the least utilized, reported by 57.6% of females and 57.4% of males. These results suggest minimal gender-based differences in coping approaches in our sample. It is important to note, however, that the small sample size of female participants in our study may have limited our ability to detect potential gender-related differences in coping strategies. All errors were minor in and are likely to decrease with increased clinical experience. This suggests that the data primarily reflect errors occurring during the learning phase of surgical training, rather than being indicative of the overall competence of the institution’s surgical staff.

A cross-sectional survey conducted by Shanafelt et al found that 70% of surgeons attributed medical errors to individual-level factors, as opposed to systemic issues^[16]. In our study, only 56.6% of participants cited incompetence as a contributing factor, while a majority (79.2%) attributed errors to systemic issues. Furthermore, Shanafelt et al reported that the most commonly cited cause of error was a lapse in judgment (31.8%), with fatigue being cited by only 6.9% of respondents. In our study, 35.8% of surgeons believed that fatigue was a contributing factor to surgical errors. Elmore LC et al found that 69% of surgical residents experienced some degree of burnout, characterized by emotional exhaustion and reduced self-efficacy resulting from occupational stress^[17]. Similarly, a study by Kuerer HM et al reported that 28% of respondents had experienced burnout at some point during their careers^[18].

Our findings partially align with the study by D’Angelo et al in terms of coping strategies and show similarity with existing literature regarding the role of fatigue in surgical error. However, differences in methodological approaches, sample demographics, and local contexts must be considered when interpreting these outcomes.

Conclusion

The high proportion of self-reported minor surgical errors in this study – predominantly among early-trainee surgeons – reflects the natural learning curve typical in teaching institutions. All reported errors were minor in nature and occurred during the formative years of surgical training, a period when trainees are actively involved in patient care under the close supervision of senior clinicians. The observed gender difference, with female surgeons reporting more errors, may be attributed to sample size variations rather than true differences in performance. The contributing factors of surgical errors were fatigue, staffing shortages, and communication breakdowns. Essential measures need to be taken to reduce surgical errors, safeguard patient outcomes, and enhance the overall well-being of surgical trainees.

Ethical approval

Ethical approval was taken from IRC of BPKIHS.

Consent

Written informed consent was obtained from the patient for publication and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Sources of funding

None.

Author contributions

DK.: writing – original draft, review and editing, resources, software; A.K.: supervision, software, writing – review & editing; A.B., R.S., and B.M.: writing – review & editing.

Conflicts of interest disclosure

The authors declare no conflict of interest.

Research registration unique identifying number (UIN)

Not applicable.

Guarantor

Dr. Abhijeet Kumar and Dr. Diwakar Koirala.

Provenance and peer review

Not commissioned, externally peer-reviewed.

Data availability statement

Not applicable.