Factors influencing adverse event and error reporting in anaesthesiology
Date
2017
Authors
Nel, Steven Robert
Journal Title
Journal ISSN
Volume Title
Publisher
Abstract
Background
Adverse events and errors are a widespread cause of morbidity and mortality in the health
care environment. Adverse event and error reporting systems have been shown to
potentially reduce the occurrence of these events, however there is still significant underreporting.
Little is known regarding the barriers to reporting of adverse events and errors in
the context of South Africa, or what emotional and attitudinal barriers may be present
regarding a formal reporting system amongst anaesthetists in the Department of
Anaesthesiology at the University of the Witwatersrand.
Methods
A prospective, descriptive, contextual study design utilizing an anonymous self-administered
questionnaire was distributed to 133 anaesthetists who attended academic anaesthetic
meetings.
Results
One hundred and eighteen questionnaires met the criteria for analysis, giving a response
rate of 92%. Barriers to reporting included a “code of silence” in medicine and blame from
colleagues. If a specified error as opposed to an adverse event had occurred, participants
were more likely to agree with barriers regarding fear of litigation, disciplinary action, getting
into trouble, as well as colleagues that may be unsupportive. Strategies to promote reporting
of adverse events and errors include senior role models who encourage reporting and
individualised feedback regarding reports made.
Conclusions
Most anaesthetists in our study disagreed with barriers to reporting an unspecified adverse
event. However, if an error has occurred, reporting behaviour may be inhibited by barriers
regarding fears of litigation, disciplinary action and lack of support. Senior role models that
openly support reporting along with individualised feedback may increase reporting rates.
Description
A research report submitted to the faculty of Health Sciences, University
of the Witwatersrand, Johannesburg, in partial fulfilment of the
requirements for the degree of Master of Science in Medicine in
Anaesthesiology
Johannesburg, 2017