Introduction In surgery, serious adverse events have effects on the patient journey, the patient outcome and may constitute a burden to the surgeon involved. This study aims to investigate facilitators and barriers to transparency around, reporting of and learning from serious adverse events among surgeons.
Methods Based on a qualitative study design, we recruited 15 surgeons (4 females and 11 males) with 4 different surgical subspecialties from four Norwegian university hospitals. The participants underwent individual semistructured interviews and data were analysed according to principles of inductive qualitative content analysis.
Results and discussion We identified four overarching themes. All surgeons reported having experienced serious adverse events, describing these as part of ‘the nature of surgery’. Most surgeons reported that established strategies failed to combine facilitation of learning with taking care of the involved surgeons. Transparency about serious adverse events was by some felt as an extra burden, fearing that openness on technical-related errors could affect their future career negatively. Positive implications of transparency were linked with factors such as minimising the surgeon’s feeling of personal burden with positive impact on individual and collective learning. A lack of facilitation of individual and structural transparency factors could entail ‘collateral damage’. Our participants suggested that both the younger generation of surgeons in general, and the increasing number of women in surgical professions, might contribute to ‘maturing’ the culture of transparency.
Conclusion and implications This study suggests that transparency associated with serious adverse events is hampered by concerns at both personal and professional levels among surgeons. These results emphasise the importance of improved systemic learning and the need for structural changes; it is crucial to increase the focus on education and training curriculums and offer advice on coping strategies and establish arenas for safe discussions after serious adverse events.
- Incident reporting
- Adverse events, epidemiology and detection
- Qualitative research
- Medical education
Data availability statement
Data may be obtained from a third party and are not publicly available. Data retrieved from the interviews are not publicly available due to the risk of identification but may be available from the corresponding author upon reasonable request and with permission from the participant(s).
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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- Incident reporting
- Adverse events, epidemiology and detection
- Qualitative research
- Medical education
WHAT IS ALREADY KNOWN ON THIS TOPIC
Prior research has indicated that ‘shame and blame culture’ has a negative psychological effect on surgeons’ well-being. In a qualitative perspective, the individual and system effects caused by insufficient transparency and incident reporting of surgical adverse events are not fully explored.
WHAT THIS STUDY ADDS
This study reports qualitative results of surgeons’ experiences related to individual and structural facilitators or barriers to transparency around, reporting of and learning from serious adverse events. Multifactorial risks in surgery may impact surgeons’ skill set and self-confidence making them more vulnerable to criticism, which might lead to decreased transparency. A mixture of individual and structural aspects needs to be met to increase transparency and learning from serious adverse events in surgery.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
Our results implicate the need of increased focus on education and surgical trainee training curriculums, as well as ensuring peer support and non-sanctioning learning structures for reporting and discussing adverse events.
Despite an increased understanding of the many negative implications of a ‘shaming and blaming culture’, handling of serious adverse events in surgery still constitutes a professional and personal issue for surgeons with impact on learning, professional development and patient safety1–7 (see box 1 for key contextual facts). Previous studies have explored the psychological impact of adverse events on different stakeholders in various hospital settings, especially related to how health professionals in general may suffer from mental distress, burn-out, loss of confidence and how interventions such as psychological or peer support programmes may help in recovery.8–22 Most of the studies are conducted in the UK or USA.2 3 10 15 23–29 Only a few studies, mainly based on quantitative data, have focused on surgeons solely.5 6 30 31
Key contextual facts related to surgery in the Norwegian healthcare system104–106
Adverse events resulting in patient injuries
At least one patient injury in 12.8% of somatic hospital admissions, as measured by Global Trigger Tool.
Patient injuries related to surgery in 4.4% of all somatic hospital stays.
A cohort study across 28 European countries assessed outcomes after non-cardiac surgery and found an overall mortality risk of 4%. The risk was considerably lower in the Norwegian setting, with a mortality risk of 1.5%.
Public hospitals with surgical departments
Twenty-two public Hospital Trusts with surgical departments at 56 locations.
Eleven subspecialties in surgery.
Surgeons across subspecialties
A total of 3431 board-certified surgeons across subspecialties.
Several studies have demonstrated that adverse events rates among hospitalised patients remain high despite significant efforts to improve quality and safety. Up to 50% of perioperative adverse events are considered preventable, which makes the occurrence of adverse events a systemic issue.32–37 Implementation of incident reporting systems with feedback loops to the hospital institutions and bodies responsible for external inspection or accreditation of the healthcare services is reckoned a key effort to reduce the number of adverse events, and this is mandatory in Norwegian hospitals. Health professionals are expected to report adverse events through these systems, and managers are required to do comprehensive follow-up analysis to reveal potential embedded risks and thereby contribute to prevent similar events.38 Although a previous qualitative study on incident reporting among hospital department managers reported a considerable cultural change over a 10-year course, with less acceptance towards individual blaming and an increased attention on the responsibility of the system as such, most studies demonstrate otherwise.39 Fear of sanctions and blame may lead to suboptimal incident reporting and limited the use of information to improve patient safety.39–49 In a context of ‘reporting fatigue’ and differences in how health professionals evaluate risk, rates of incident reporting are not considered a sufficient standalone indicator of quality and safety.42 50–52 Knowledge on the effect of transparency and collegial discussions on reporting and learning from adverse events in surgery is therefore crucial for the individual surgeon in addition to a systemic and public perspective.
To the best of our knowledge, this study is the first to report qualitative results of surgeons’ experiences related to individual and structural facilitators or barriers to transparency around, reporting of and learning from serious adverse events in a setting outside of the UK and USA. In this study, a serious adverse event was defined as any serious incident as described by the participants, with no attempt of distinguishing between expected adverse events, calculated complications or between simple mishaps to failure or blatant errors.52
Aim and research questions
The aim of the study was to explore individual and structural facilitators and barriers to transparency around, reporting of and learning from serious adverse events among surgeons in a Norwegian context of a universal public healthcare system. Three key research questions were explored:
Which factors enable reporting and transparency among surgeons concerning serious adverse events?
What barriers do surgeons experience in reporting and discussing serious adverse events?
How do serious adverse events and transparency about the events impact learning?
Study design and setting
This paper presents results from an inductive exploratory and descriptive study design, based on semistructured individual interviews. We chose an inductive, exploratory and descriptive design with the intent of gaining in-depth knowledge into a novel setting, with attention to data-driven analysis.53 54
Participant recruitment and characteristics
Participants were approached by email and recruited by strategic sampling from four university hospitals, one from each of the four Regional Health Authorities in Norway. A strategy of purposive; strategic sampling was chosen based on the logic of achieving ‘information rich’ samples, by ensuring that participants included held in-depth insights into the phenomenon of adverse events in surgery.55 56
All fifteen surgeons (11 men, 4 women, age 38–65 years) with a minimum of 10 years of experience (range 11–38 years) and still clinically active that were invited to participate in the study were included. Seven of the participants were board-certified specialists in gastrointestinal surgery, six participants in cardiothoracic surgery, one in general surgery and one participant in orthopaedic surgery. All except three surgeons currently held or had previously experience from various senior positions with managerial responsibilities, ranging from senior consultant to head of department or division. Geographical distribution: Northern Norway Regional Health Authority (three participants), South-Eastern Norway Regional Health Authority (nine participants), Central Norway Regional Health Authority (two participants), Western Norway Regional Health Authority (one participant).
Based on a semistructured interview guide, individual interviews were conducted between December 2021 and February 2022 (each interview approximately 1-hour duration). Due to the COVID-19 lockdown, all interviews were carried out digitally using virtual meeting software (teams). All interviews were recorded and transcribed. One of the participants requested the transcript returned for comment and correction, and we accommodated this request. We chose to base our data collection on a semistructured interview guide, rather than a rigid, prefixed guide or survey, as this enabled the researcher to ask the participants follow-up questions based on their response.
We analysed the interview data inductively, based on the procedures of qualitative content analysis.53 54 The analysis consisted of seven procedures, starting with an open reading process of all interview transcripts. We took notes immediately after reading, followed by identification and condensation of all meaning units. Codes and subcategories were proposed, prior to suggesting overarching themes across all 15 interview transcripts. Meaning units, condensed content, codes, subcategories and themes were set up in a separate digital matrix, one for each interview transcript. Additionally, we compiled data manually for each interview, marking different topics, contrasts and similarities by paper and pen. Finally, results from all transcripts were set up in a document with overarching themes and subordinate categories across the entire matrix, with the objective of organising patterns across the data. Subcategories and themes were discussed and refined in collaboration among the researchers.57
During the process of writing this manuscript, we cross-checked all transcripts for subcategories related to disadvantages with reporting, peculiarities with surgery in contrast to other medical professions, examples of technical errors and the value of role models and support from managers/seniors. In addition, a quantitative cross-check of the participants’ application of various terms (‘error’, ‘misjudgement’, ‘adverse event/event’, ‘serious adverse event’, ‘complication’, ‘patient injury/severe injury’) was performed, referred to as quantitative analysis of qualitative data58 59 to ensure the reliability of interpretation.
The predominant objective with trustworthiness in qualitative research relates to ensuring that the results are worth paying attention to, while aligning with the concepts of credibility, dependability and transferability.54 60 61 Credibility was assessed with attention to the aim of the study and the sample size.54 61 62 The interview transcripts demonstrated a comprehensive amount of data, covering a wide range of topics related to processes of transparency around, reporting of and learning from adverse events. Hence, the sample size held adequate information power relevant for this study.63 The methodological quality of the interview transcripts was checked in accordance with the consolidated criteria for reporting qualitative research.64 Data stability related to how other researchers are provided with sufficient information to follow the trail of decisions made by the current researchers (dependability) were facilitated by sensible participant selection and demonstration of the analytical process. By elaborating on the study setting and participant characteristics, this study’s results may have the potential of extrapolation to other groups of surgeons, clinicians in general or other geographical contexts (transferability).62 65
Patient and public involvement statement
As this study focuses on surgeons’ individual experiences concerning transparency around, reporting of and learning from serious adverse events, patient involvement was not considered feasible. However, an early version of the manuscript was presented to a former Patient and User Ombud. Her impact regarding the interpretation of the study’s findings on reporting culture, lack of leadership and support, with implications for patient safety was used in the discussion part of the manuscript.
The inductive qualitative content analysis eventually resulted in the identification of four themes
Individual factors: the participants described several individual factors influencing serious adverse events.
Structural factors: serious adverse events were experienced to have strong associations with structural factors.
Negative implications of transparency: transparency of serious adverse events may have negative implications for surgeons personally and professionally, as well as implications for general quality and patient safety.
Positive implications of transparency: surgeons considered transparency and sharing of serious adverse events to have positive implications for individual, and systemic learning, as well as having positive impact on the relationship between surgeons, patients and next of kin.
In the following, we present the results theme-wise, including subcategories shown in bullet points for each theme (box 2). The results are accompanied by example quotations from the participants (boxes 3 and 4), and subsequently shortly summarised.
Overarching themes and subcategories
Theme 1: individual factors influencing serious adverse events
The individual surgeon constitutes a risk factor to patient safety.
Variation in manual and technical skills that are required.
Self-confidence affects judgement and decision-making, as well as the willingness to report and share what was considered to be ‘individual technical-related errors’.
Theme 2: structural factors influencing serious adverse events
Embedded risks and complexity/multifactorial risks in surgery.
Culture for reporting and conducting morbidity and mortality conference.
Lack of technical training and guidance.
Lack of training in coping strategies and how to deal with consequences from serious adverse events.
Manager facilitation of a non-sanctioning working environment.
Role models and collegial support.
Theme 3: negative implications of transparency
Fear of sanctions and/or criticism; losing position or seniority.
Personal discomfort and feeling of guilt.
Issues with professional identity and confidence in one’s skill set.
Theme 4: positive implications of transparency
The surgeon receives collegial and managerial support.
The individual burden of guilt gets reduced.
The surgeon gains trust from patients and next of kin.
Reporting serious adverse events serves as self-protection against sanctions.
Positive effects on learning (outcomes).
Example quotations for theme 1 individual factors influencing serious adverse events and theme 2 structural factors influencing serious adverse events
Individual factors influencing serious adverse events
You must be able to stand taking the risk, resist the pressure in executing actions where the margins are small between success and failure. However, we do not want the old-fashioned psychopaths who stood there shouting to everyone around and were masters of the universe; we must have people who approach their profession and their environments with humility, where you must function like a kind of athlete—while at the same time being part of a team. (Participant 1)
A surgeon who is very uncertain and always considers what might possibly go wrong may undermine the patient’s necessary trust. Within many surgery disciplines there is a fine balance between doing too little and doing too much, and between making mistakes or doing it correctly. We decide in favor of something, and afterwards we may say that this was right or possibly wrong. (Participant 8)
Any error I have made in the operating room has minimal consequences for me. As long as reporting is rather a matter of doing it voluntarily you have to have extremely high ethical standards to do it. (Participant 11)
Structural factors influencing serious adverse events
We discuss selected complications at morbidity and mortality (M&M) meetings. This entails a lack of personal care for the responsible person. It’s very much a matter of chance whether the one reporting receives an encouraging pat on the shoulder or the offer of a de-briefing afterwards. (Participant 2)
One might have spent more time on it (discussion and in-house teaching) but the days are packed and you'd need to gather people. (Participant 13)
We learn a great deal from the corrections that appear during the M&M meetings. Being particularly aware of a point in an action that might lead to complications. (Participant 15)
When I started out as a surgeon, I had a very good mentor, leader, being a brilliant role model, always leading by example and sharing his mistakes. That made a culture and atmosphere of transparency and sharing; everyone was expected to make mistakes and one should talk about that and learn from it to avoid it from happening again. (Participant 9)
After experiencing a major adverse surgical event my leader patted my shoulder and said that behind every great surgeon lies a large graveyard on a good evening. And this is how the talking went at that time, in the early '90s. (Participant 3)
Example quotations for theme 3 negative implications of transparency and theme 4 positive implications of transparency
Negative implications of transparency
If one is afraid of being considered a less good surgeon, or afraid of losing face among colleagues, or not being allowed to operate any more, one would try to avoid talking about it. (Participant 9)
Staying silent about everything you do wrong and only talking about successful operations is very common in my profession. (Participant 14)
I believe that bringing too much emotional reactions into a work environment may seem wrong. A culture of openness in an environment must have a more rational basis. Therefore, the complication meetings were established, because they provide a different context. (Participant 3)
It is very hard at that moment to say that the surgical procedure did not go well but one must be honest and explain what happened and say that I am deeply sorry. (Participant 7)
Looking very cynically at it, it (adverse event) generates a great deal of extra work. (Participant 9)
Therefore, it is much more difficult to admit (errors) because it is a matter of one’s technical mastery. (Participant 11)
Positive implications of transparency
Although this is very tough for the individual both that person and everyone who shared in the experience understand that it is positive because I and all the others will learn from this process. (Participant 14)
I strongly recommend being open with the family because it lifts the weight from your shoulders and will liberate you from hiding something. (Participant 4)
I talked with the patient and fully admitted that this was not up to standard, and she tackled this much better than I had expected. (Participant 5)
I should have tackled this in another way, especially signaling to younger colleagues that it is very positive to talk about this. (Participant 10)
One key point is that once damage has been done it is vital to limit the effects as much as possible. For this you must be totally open, very early. We still have a long way to go. (Participant 11)
In summary, all surgeons reported having experienced serious adverse events, or misjudgements, describing these as part of ‘the nature of surgery’. Most surgeons reported that established strategies failed to combine facilitation of learning with taking care of the involved surgeons. This applied specifically to lack of formalised training and learning to handle consequences of serious adverse events, and to challenging conversations with patients and next of kin.
Accounts of substantial disparity in surgical leaders and colleagues’ ability to address serious adverse events were given, 10 of 15 participants described the morbidity and mortality conferences (M&M) as more or less random and unstructured. Some of the surgeons feared that transparency could affect their future career path negatively, although some of them also indicated that by reporting individual technical-related errors, misjudgements and complications, they could protect themselves from sanctions in case of investigation or external inspection. Transparency towards managers and colleagues were by some felt as an extra burden, fearing that transparency of their own or colleagues’ errors could affect their reputation. Some participants described how lacking structures or safe arenas at work contributed to their sharing their experiences outside of work, because they simply needed someone to talk to.
The factors of negative impact were described as important obstacles to transparency. Some participants argued that since the surgeon’s role as team leader presupposes a high level of self-confidence and courage, attention to and transparency of individual technical-related errors could negatively influence the surgeon’s confidence in their skill set. However, positive implications of transparency were linked with factors such as minimising the surgeon’s feeling of personal burden; lifting weight off their shoulders, building trust between surgeon and patient or next of kin, and that a culture of collegial sharing positively provides learning opportunities.
Several of the surgeons referred to distinct features of surgery compared with non-surgical specialties, with the association between operating surgeon and appearing adverse events. Although risk in surgery is perceived as multifactorial, features with the individual surgeon as a risk factor to patient safety were described as strongly attributed to apparent and immediate adverse outcome. Non-surgical specialties were described as having multidisciplinary collaboration and deliberation, resulting in system-oriented adverse events with less potential negative impact on patient outcome. In comparison, surgeons reported their technical skills and individual judgement to have clear impact on patient outcome. All participants reported insufficient structured and formalised training in surgical techniques and lack of learning opportunities on handling wider professional and personal consequences of surgeons’ individual technical-related errors or misjudgements. Participants additionally argued that some non-surgical specialties had developed more sufficient internal systems and routines for professional and personal support and learning compared with surgical specialties. Some described the latter as being related to a stereotypical recruitment to the surgical profession, valuing personal traits such as competitiveness and risk-seeking. Improving selection criteria and supervision in surgery were highlighted as important means for improving quality and safety and refining the professionalism of the specialty. However, most of the participants indicated that the younger generation of surgeons in general combined with the increasing number of women in surgical professions, contribute to maturing the culture with more acceptance and demand for reporting and sharing of challenging experiences.
We explored the experiences of transparency around, reporting of and learning from serious adverse events from 15 surgeons in the Norwegian context. Our results indicate that existing strategies fail to combine facilitation of learning with taking care of the involved surgeons, and substantial disparity in leaders and colleagues’ ability to address serious adverse events. Transparency towards patients, next of kin, managers and colleagues, were by some felt as an extra burden, however, it could minimise the surgeon’s feeling of personal burden, building trust between surgeon and patient or next of kin, and positively impact learning. Reports were given of a development towards more acceptance and demand for reporting and sharing of challenging experiences related to serious adverse events, argued by several participant to have association with a gender and generational shift in the surgical profession.
Strengths and limitations
This main strength of this study is its dual approach of exploring reporting and transparency associated with serious adverse events, as both an individual issue for surgeons with structural implications that may impact learning, quality and potentially patient safety. The methodological and geographical context along with the substantial clinical experience of the participants holding are also key strengths. This provides the study with comprehensive data of the complexity of risks in surgery. Our data held sufficient information power, and the sample size of 15 participants was adequate and reinforced the results’ trustworthiness.62 63
Due to qualitative research’s scope of exploring limited parts of reality, transferability of results has its limitations. Despite our attempts to balance between gender, age and clinical specialties the distribution of the participants does not fully reflect the current gender and generational balance among surgeons in a Norwegian context. The study reports surgeons’ perspectives only limited to a Norwegian setting, which given the gap in knowledge serves as a strength. However, including university hospitals only and not smaller, locally based hospitals, may impact the results related to cultural aspects and maturity related to transparency and reporting. This study explored how serious adverse events may influence surgeons’ professional lives mainly and not potential implications on their personal, family lives. The latter could invoke future studies.
Training, learning systems and M&M conferences
We found variation in support and learning systems with predominantly non-systematic training and management follow-up after adverse events. None of the participants had been offered any structured training in dealing with consequences from adverse events during their medical education and surgical trainee training or later in their career. In another study, 55% of the surgeons stated to have participated in discussions about whether an adverse event was preventable or not, and 26% of those who reported very or somewhat difficult experiences participating in the discussions were more negatively affected by the adverse event.30 These results demonstrate the importance of disclosure: the factor of potential collective learning about preventability and the negative effects non-disclosure may have on the surgeons. Although our participants mentioned that collegial and managerial discussions after adverse events sometimes occurred, these happened rather infrequently and in an unstructured setting; M&M conferences varied in structure and four participants reported that this type of meeting was not conducted in the department or unit they were affiliated with. One participant even described that M&M conferences had been ceased due to an unfortunate ‘shame and blame culture’. These accounts indicate that support and learning systems are randomly and insufficiently present in Norway.
According to a systematic literature review by Vreugdenburg et al,66 M&M conferences require a system focus to be helpful, but often tend to lack ‘defined structure, objectives and resource support’. A survey of consultant surgeons in the UK found that more than one-third of the surgeons did not routinely attend M&M meetings.67 Results also revealed a willingness to talk about adverse outcomes, but this was constrained by a fear of negative repercussions.67 Similarly, the American College of Surgeons has highlighted the need for change in the surgical M&Ms current format, to make conferences ‘necessary and sufficient’.68 Our results validate that changes are needed in the structure, content and frequency of M&M meetings in the Norwegian setting, with emphasis on systemic learning.
Facilitation of safe arenas and structured peer support
Another predominant finding in this study was anticipation of lacking formal leadership support. Concepts such as ‘safe spaces’, ‘first responders’, ‘peer support’ programmes or ‘self-selected buddy relationships’ have been launched in other countries.69–72 The Canadian Patient Safety Institute developed a manual to address the psychological safety of health professionals in general which includes strategies for building leadership support, and a toolkit with examples and recommendations for how to establish and execute a peer support programme.70 The Brigham and Women’s Hospital offers clinicians a team of designated supporters (physicians and nurses).69 As part of a normalisation of any reactions that the clinician might experience, the designated supporters are trained to call the clinician directly to ask if they think a conversation about what happened could be helpful.69 A recent evaluation report of the ‘buddy’ concept implemented in two Danish university hospital departments indicated that a formalised system of peers offering support to health professionals could serve as a ‘safe space’ after an adverse event, to share their emotional vulnerability and professional insecurities.72 Ultimately, these past results and this study indicate that the combination of renewing the structure of dissemination of adverse outcomes in M&M meetings and offering relevant peer support systems may contribute to facilitate reflections and positive learning experiences. This resonates with an important feature in the resilience in healthcare concept where learning from everyday work should add to learning from adverse events.73 74 The latter is suggested ‘less controversial and less threatening’ to health professionals after experiencing serious adverse events.75–77 The positive value of learning from ‘near misses’: unfortunate events that do not fully unfold into adverse outcome, to improve patient safety was also recently reviewed by Woodier et al.78
Surgical trainee training: recruitment and curriculum
All participants in our study reported that they had worked with colleagues that, according to their judgement, should not have been recruited to a surgical path. The issue with variation in skill set among surgeons was recently discussed in the work of Purdy et al,79 highlighting the importance of developing specific curriculums and assessments related to skills and standards for surgical judgement and leadership even though this is not a part of the formal surgical trainee training. Differences in how for instance general surgery trainees and internal medicine trainees discuss and evaluate risk for surgically complex patients have been confirmed by research in the past.51 According to Aggarwal80 risk, complexity and clinical judgement should be seen in conjunction with ‘ability of education, quality improvement and health system strategies to affect care for surgically complex patients’. However, our results corroborate the aspects of complexity and multifactorial risks associated with surgery. The combination of individual performance of the surgeon and individual patient factors could make it difficult to manifest errors to the specific operating surgeon, although some of our participants argued that individual performance attributes such as technique, volume and subsequent accountability, are underestimated as risk factors for patient safety. All participants had experienced specific individual errors during their career, which they accounted to having direct association with their application of technique, (mis)judgement or professional experience. Self-confidence in turn, affected their future judgement and decision-making. One of the participants claimed that surgeons used the term ‘complication’ instead of ‘error’ to avoid accountability and to signal that the adverse outcome was impossible to avoid. Suggestions were raised to develop a more structured approach to patient injury data, with attention to repetitive individual appearance of surgical complications. These results are not in line with the modern patient safety literature in general. This includes the logic of resilience in healthcare advocating that it is prudent to move away from individualised performance factors as explanatory models for errors in healthcare and encourage more attention to system improvement ‘by viewing medical errors as challenges that must be overcome’.52 74 81–83 A recent publication illustrates the paradox in the individualised models for errors in healthcare, by highlighting how medical school ethics curriculums in the UK still predominantly emphasise ‘individual action’, even though patient safety literature clearly recognises the collective and organisational contributions to failures in healthcare.84 A multilevel perspective to safety which acknowledges the embedded system complexity may encourage and motivate health professionals to share and discuss adverse events as well as reducing their personal discomfort.8 23 85–91
Compiled with our results showing a lack of attention to the complex professional and personal processes of dealing with consequences from adverse events in surgical training, facilitating transparency should start with early on recognition of serious adverse events as complexity issues, that often require complex investigation and explanations. We argue that surgeons need to be introduced to the principles and methods for dealing with serious adverse events early on in their education. Introduction to different psychological reactions, and the wider consequences in terms of dealing with patients or next of kin involved in the event, illustrated by simulated scenarios, could give some valuable context to the preparedness required from them as surgeons. Some of the surgeons expressed how they were motivated from participating in this study and wanted to suggest incorporating training sessions in adverse event related coping strategies for young medical students and trainees. In addition to the established criteria for technical professional skills for medical students and surgery trainees, a generic criterion in the national guidelines that points to health professionals’ individual responsibility to obtain self-efficacy has been described.92 We suggest that the curriculum for surgery trainees should align with certain criteria for dealing with consequences from adverse events and surgical judgement that exceeds the current generic of individual responsibility.
Aligning system level and individual level learning by transparency and reporting
Incident reporting is a widespread, internationally recognised effort, aiming at identifying the underlying risks in the systems, to determine whether there is a subsequent need to investigate, analyse or implement further actions.44 47 49 50 93 Incident reporting as a tool to improving quality and safety is debated in the literature claimed to hamper informal learning opportunities and not necessarily contribute to accurately detecting errors.43 44 52 94–96 Anonymous reporting could, however, serve as a simple way of putting patient safety on the agenda and thereby creating awareness about risks.39 42 97 98 Our participants’ reactions were not conclusive; on one hand they feared the negative effects from reporting, on the other hand it could protect them from sanctions in case of investigation or external inspection. This duality represents a ‘catch 22’ for transparency: as surgeons may be more vulnerable to criticism due to the embedded multifactorial risks in surgery and conditions related to individual, technical skills and procedures, this may contribute to decreased transparency from distrust and the fear of shame, blame and various types of sanctions.
As national system audits in Norway have revealed differences across health regions and hospitals in identification of risks and in reporting frequency, the assumption from our study is that obstacles to reporting and transparency occasionally are perceived as overshadowing the facilitators and gains from it.46 Our data suggest that reporting adverse events through formalised reporting systems, may serve as a supplement to structured routines for meetings and discussions of adverse events at various system levels. This take validates a recent review reporting on the promotion of formal and informal communication and teamwork and how it allows health professionals to consolidate their knowledge, fostering ‘leading initiatives to improve patient safety’.99 The urgency of taking actions to ensure establishment of synergies between health professionals’ safety and patient safety is recognised as a key future policy topic and paying attention to the connections between individual surgeon and system factors.100 101 Illustrated by this study’s results, a less fragmented application of for instance M&M conferences, a systemic case-based approach, with boundaries against attention to specific individual performance factors and where aspects of successful activities, techniques and outcomes become part of the discussions, may serve as a means of aligning system-level and individual-level learning. In turn, it may add to meeting the need for safety from both surgeons and patients.
Implications: potential ‘collateral damage’
We think that our study reflects transparency as an attribute to both professional safety and quality and patient safety: (1), transparency requires a safe work and learning environment attained by managerial and collegial support, (2) lacking transparency may contradict learning opportunities on both individual and system levels and in that aspect potentially have unfortunate impact on patients. Subsequently, this study raises implications to different stakeholder levels in the healthcare system. The results primarily demonstrate individual implications for surgeons and clinicians in general, as well as for patients. Second, some of the results identify structural issues that need to be addressed. Failing in addressing individual or structural factors that may affect transparency around, reporting of and learning from serious adverse events may result in potential ‘collateral damage’ harming both surgeons and patients (see figure 1). Thus, part of moving the cultural shift forward is the recognition of barriers to transparency as a patient safety challenge, hampering both collective learning and individual motivation, engagement and learning.43 84 93 Given these indications, we suggest that hospital management, policy-makers and regulators in the Norwegian healthcare system ‘derandomise’ support and learning systems in medical education and surgical trainee training.52 Government bodies with their policies and budget allocations have a prudent task in instructing healthcare providers to rig postgraduate clinical education and teaching hospital system in a way that openly address and discuss learning points from serious adverse events in parallel addressing the needs of psychological and peer support for the involved surgeons.
The figure 1 illustrates how this study’s results interconnect, entrenching multilevel implications.
This study implicates that transparency of serious adverse events among surgeons represent a complex issue requiring a range of different measures to meet the needs of surgeons’ safety and ensuring learning opportunities, both in terms of technical training and inclusion of basic principles and methods related to dealing with serious adverse events. Additional systemic implications are: (1) providing ground for more common approaches to reporting and dealing with adverse events across hospital regions,46 49 (2) encourage teaching institutions to ensuring sufficient supervision of surgeons during trainee training and 102 (3) contributing to ensuring accountable systems in employment processes by establishing barriers to detect surgeons with recurring professional challenges and need for additional technical skill training or supervision.103 If these complexities are met from the path of education, during trainee training, at the same time as it is adequately handled by the hospital management, these measures may improve the quality and safety for patients.
This study provides valuable insights to individual and structural facilitators and barriers to transparency around, reporting of and learning from serious adverse events among surgeons. The combination of multifactorial risks in surgery and the individual performance of the surgeon may put skill set and self-confidence on display making them more vulnerable to criticism, which might lead to decreased transparency. Combined with a lack of structured training in coping strategies and lack of trust and support from close colleagues and leaders, the culture of keeping difficult experiences to oneself potentially becomes fortified.
Facilitation of training in coping strategies, ensuring safe arenas for discussions as well as pushing structural changes in education and training curriculums are systems changes that may counteract the unfortunate potential of causing ‘collateral damage’. These types of changes are crucial both from an individual surgeons’ point of view, and from a system’s approach to learning, resilience, quality and patient safety. Further studies are vital to investigate into the wider effects of these structures.
Data availability statement
Data may be obtained from a third party and are not publicly available. Data retrieved from the interviews are not publicly available due to the risk of identification but may be available from the corresponding author upon reasonable request and with permission from the participant(s).
Patient consent for publication
This study involves human participants and was approved by the Norwegian Centre for Research Data reference number: 594289. Participants gave informed consent to participate in the study before taking part.
The authors would like to acknowledge Anne Lise Kristensen, previous Patient and User Ombud, for her valuable comments in developing the final manuscript.
Contributors SFO initiated and designed the study, recruited participants, and conducted the interviews, identified and condensed all meaning units, suggested codes as well as drafted the manuscript. OT co-designed the study, assisted in recruitment of participants, read all transcripts, and made substantial contributions to the drafting of this manuscript. SFO and OT analyzed the data in collaboration, refining overarching themes and subcategories. KS and ES contributed substantially to the drafting and revision of the paper.
Funding This work was supported by Universitetet i Stavanger.
Competing interests None declared.
Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.
Provenance and peer review Not commissioned; externally peer reviewed.
Author note Sina Furnes Øyri; MSc, LLM, PhD; , Department of Quality and Health Technology, Faculty of Health Sciences, University of Stavanger, Norway; Department of Research, Stavanger University Hospital, Norway. Ole Tjomsland; MD, PhD; , South-Eastern Norway Regional Health Authority. Kjetil Søreide, MD, PhD, FRCS (Edin), FACS FEBS (hon), Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway, SAFER Surgery, Surgical Research Group, Stavanger University Hospital, Stavanger, Norway, Department of Clinical Medicine, University of Bergen, Bergen, Norway. Eldar Søreide, MD, PhD, Faculty of Health Sciences, University of Stavanger, Norway, Section for Quality and Patient Safety, Stavanger University Hospital, Norway.