For many individuals, working to find a solution and prevent future events can help. “Many surgeons involved in quality improvement or implementation science were motivated by an adverse event during their career,” Dr. Brenner said.
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April 2023Key Steps
Dr. Balakrishnan said that there are some key steps that can be taken to prevent the negative effects of having made a medical error. A morbidity and mortality conference can be a good place to start (Otolaryngol Head Neck Surg. 2018;158:273–279).
According to Dr. Balakrishnan, these steps include the following:
- Ensuring that our event reporting and review activities focus on system and process, not on individual blame. This encourages reporting by creating a climate of psychological safety.
- Using structured and facilitated forums to review events and identify opportunities for improvement, as well as long-term follow-up and “loop closure” (reporting back on these improvement activities).
- Separating review of provider performance from system and process review and ensuring that the former is supportive, focuses on improvement, includes effective coaching, and is kept confidential.
- As leaders, making sure that we support and implement these steps and submit to the same processes, so the rest of our teams feel safe doing so.
- Setting up robust wellness programs to support all clinicians, including those at risk for second victim effects.
“Healthcare is a socio-technical system, so we must examine systems and processes, individuals, and the interface between them, as well as how individuals interact with each other,” Dr. Balakrishnan said. “Disregarding any of these components will limit our ability to reduce errors and to cope with and learn from them when they do occur.”
Katie Robinson is a freelance medical writer based in New York.
Mishap Reports
While data on otolaryngology-related medical errors are sparse, here are some reports on medical mishaps in the profession:
Medication
Of the 534 members of the American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) who responded to a 2021 online survey, 25% reported at least one patient safety event in the past 10 years. The study, which focused on intraoperative sentinel events, reported that medication errors were the most common type of error, while wrong site or procedure, retained surgical item, and operating room fire were also reported as medical errors (OTO Open. 2020;4:2473974X20975731).
Perioperative and Airway Management
Perioperative and airway management errors were reported more frequently in otolaryngology compared with other inpatient and outpatient departments across hospitals, according to a 2020 study. Otolaryngology departments reported lower proportions of events related to diagnosis and treatment, laboratory results and specimens, medication and fluids, and safety and security, however. In otolaryngology, the most reported adverse events occurred perioperatively, followed by issues concerning equipment and medical devices (Laryngoscope. 2021;131:509–512).
Misjudgment
Adverse events aren’t infrequent in facial plastic surgery, a 2021 study reported. The researchers surveyed 253 members of the AAO-HNS and American Academy of Facial Plastic and Reconstructive Surgery. While surgeon misjudgment or patient non-adherence were commonly cited, systems-based factors were rarely reported as reasons for adverse events (Am J Otolaryngol. 2021;42:102792).
In 2020, national data showed that over half of otolaryngologist respondents in the United States reported instances of attempted oral intubations among patients with laryngectomy, with a mortality rate of 26%. Most of these errors occurred in otolaryngology patients, but the errors were not made by otolaryngologists (Otolaryngol Head Neck Surg. 2021;164:1040–1043).