Despite the high safety level of modern healthcare, preventable incidents due to human error still remain.1 Studies across the world have shown that between 3 and 17% of all hospital admissions result in an adverse event.2–10 In this context, Zegers et al.11 reported an incidence of 5.7% of adverse events in the total population of 1.5 million patients who were admitted to a Dutch hospital in 2004. Forty percent of these adverse events were attributable to human error or organisational factors. Dutch hospitals are requested to provide a complaint and incident reporting system. This allows analysis of the underlying cause of adverse events that occur related to patient healthcare or intercollegial incidents.12 We suggest that evaluation of complaints and incidents may improve the quality of healthcare organisation and patient safety.
Although conventional education has placed great emphasis on acquisition of medical knowledge and practical skills, it is increasingly recognised that sufficient competency in nontechnical skills is also essential to succeed as a medical specialist.12,13 Reducing the incidence of complaints and incidents involves focused education of interns and residents with respect to healthcare quality, communication and management skills. An example of this focused education is the CanMEDS (Canadian Medical Educational Directives for Specialists) Physician Competency Framework, which provides a medical education and practice platform aiming to improve patient care quality and to reduce human error that is worldwide adapted.13 The CanMEDS 2000 project was established to change the focus of specialty training from the interests and abilities of providers (supply) to the needs of the society (demand).13 CanMEDS defines seven roles that play a key role in medical education and practice: medical expert, communicator, collaborator, health advocate, manager, scholar and professional.
Although anaesthesia service is often perceived as a technical specialty, the importance of nontechnical skills is evolving in the performance of the modern anaesthesiologist. In the Netherlands, nontechnical training for anaesthesiology residents consists of competency education based on the CanMEDS roles.
Complaints and incident reports are valuable sources to get feedback about deficiencies in anaesthesia services. Thus, these reports can be used to improve departmental procedures as well as infrastructure. In this context, we hypothesise that many complaints and incident reports about anaesthesia service are related to roles addressing nontechnical skills. To study this distribution, we attributed complaints and incident reports about anaesthesia practice to the different roles as defined by CanMEDS.
The medical complaints and incident reports database of the Department of Anesthesiology of the VU University Medical Centre Amsterdam was interrogated on the nature, frequency and the relation of the reports to one of the seven roles of CanMEDS. The VU University Medical Centre Amsterdam is an academic teaching hospital in the Netherlands, in which on average 15 000 surgical procedures are performed per year. Two independent reviewers evaluated all reports received between 2001 and 2007 in a retrospective fashion.
Complaint and incident classification
Every Dutch hospital has to establish rules for filing complaints and has to enrol a committee handling these complaints. This committee also offers recommendations for quality improvement of healthcare. Moreover, Dutch hospitals are requested to have an anonymous incident reporting system. Whereas the Dutch law provides a definition of complaints, the regulation for incident reports is described in a healthcare incident reporting procedure. In general, complaints are defined as displeasure expressed to the hospital about the conduct of (or on behalf of) a care provider. Complaints are always made by or in the name of a patient. In contrast, incidents are defined as unintentional events that have led to (or could have led to) an injury to a patient. In our hospital, every care provider has to report incidents.
We attributed all reports (complaints and incidents) that were received by the Department of Anaesthesiology to one of the following seven roles: medical expert, communicator, collaborator, health advocate, manager, scholar and professional. These roles were defined according to the description of the CanMEDS Physician Competency Framework:13
- The role of medical expert includes knowledge and skills according to the profession's current standards, adequate application of diagnostic, therapeutic and preventive measures of the discipline, delivery of adequate and ethical patient care and the capacity to quickly find information for improving patient healthcare.
- The role of communicator describes the capacity to establish adequate therapeutic relationships with patients. The communicator listens carefully, obtains relevant patient information in an effective way, adequately discusses medical information with patients and family members and reports on patient information in an oral and written way.
- The role of collaborator addresses the capacity to consult effectively with or to refer adequately to other healthcare providers. The collaborator delivers adequate collegial advice and aims at effective interdisciplinary collaboration and chain care.
- The role of manager includes the finding of a balance between professional patient care and personal development. The manager works effectively and efficiently in a healthcare organisation, wisely allocates available healthcare resources and uses information technology for the optimisation of patient care and lifelong learning.
- The role of health advocate addresses the knowledge about determinants of illnesses as well as the identification of these determinants. The health advocate contributes to the health of patients and communities, acts according to relevant legislation and adequately in case of healthcare incidents.
- The role of scholar describes the capacity to assess medical information critically to contribute to the development of professional and scientific knowledge, to develop and maintain a personal ongoing education plan and to contribute to healthcare education.
- Finally, the role of professional describes the capacity to deliver high-quality patient care with integrity, honesty and compassion. The professional shows appropriate personal and interpersonal behaviour, is conscious of his/her personal limits and practises consistently with the ethical standards of the profession.
To classify all complaints and incidents according to these roles, all reports were analysed and subsequently summarised in a one-sentence statement. Thereafter, it was decided to which CanMEDS role the report could primarily be attributed. This attribution was done using the root cause analysis methodology. Subsequently, an independent reviewer categorised all reports according to one-sentence summaries. The categorisation into the seven roles of both reviewers was compared, and in case of dissimilarities, consensus was reached between both reviewers by classification of the original report. A description of the reasons of reports in terms of ‘teeth damage’, ‘medication failure’ and ‘communication between professionals’ was made by one reviewer and checked by the other reviewer.
The reports were further analysed for date of incident and sex of reporter. In addition, the reports were classified according to the phase in the perioperative period, which was subdivided into the preoperative period (e.g. disagreement between preoperatively determined intraoperative technique and actual intraoperative strategy), the intraoperative period and the postoperative period (complaints about incidents in the recovery period after anaesthesia). Reports not related to the operating room were separately classified.
Data were analysed using standard statistic software. Data values in the manuscript are represented as counts or frequencies.
Type of complaints and incidents
The number of reports in the study period was 169 on a total of 84 252 anaesthesia-related procedures (0.2%). Reporters were more often women (60%). Whereas complaints were reported by patients (58%), related family members (39%) or involved professionals (3%), incidents were always reported by healthcare providers (100%).
In general, reports were related to the preoperative and intraoperative period and less to the postoperative period (Fig. 1). Other reports concerned the pain service or treatment of pain (10%), the preoperative assessment outpatient clinic (9%) or issues that were not related to the operating rooms (e.g. complaints related to a shockroom presentation).
Reasons for reports are shown in Table 1. The largest number of complaints was related to cancellations of surgery, insufficient information regarding the anaesthetic technique or teeth damage due to laryngoscopy. Incident reports mainly concerned technical problems (e.g. dysfunctional equipment), medical complications, planning of surgery, medication failure or miscommunication between professionals. Table 2 shows the actual involvement of anaesthesia service in complaints and incident reports submitted to the Department of Anaesthesiology. These data show that 9% of the reports were attributed to the anaesthesia service, though anaesthesiologists or anaesthesia nurses were not actively involved in the event that has led to the complaint or incident report.
Attribution of complaints and incidents to Canadian Medical Educational Directives for Specialists roles
The attribution of the complaints and incident reports to the different roles as defined in the CanMEDS framework is shown in Fig. 2. Examples of complaints and incident reports from our database are given in Table 3. Of all complaints and incident reports, 77% could be attributed to the roles of ‘medical expert’ and ‘manager’. Complaints were additionally classified as related to the roles of ‘communicator’ (communication between healthcare provider and patient) and ‘professional’. With respect to incidents, a number of reports were related to the role of ‘collaborator’ (communication between healthcare providers). There were no complaints or incident reports that could be classified as related to roles of ‘health advocate’ or ‘scholar’.
The present study attributed complaints and incident reports about anaesthesia service to one of seven roles defined by the CanMEDS. Our data show that these reports are often related to nontechnical skills such as those of manager, professional and communicator, suggesting that training of nontechnical skills as part of the anaesthesia education programme may be important to improve the quality of healthcare provided by anaesthesiologists.
Adverse events in healthcare are frequently based on human or organisational error.2 While anaesthesiology is still perceived as a rather technical specialty, nontechnical skills become increasingly important. Particularly, the role of manager is growing rapidly as the complexity of perioperative patient care in the operating environment demands more and more skills such as team working, planning, resource management and decision-making.12 Anaesthesiologists also face unique communication challenges with anxious patients and patients with drug-induced altered consciousness. In the areas of regional analgesia, pain management and intensive care, anaesthesiologists have direct contact with conscious patients.14,15 Previous studies showed that causal factors of preventable incidents in anaesthesia include inattention or carelessness, pressure of time, failure to follow personal routine, failure to follow institutional practice but also communication problems and dependency on other personnel.16–18
Because we regard reports about complaints as feedback that allow improvement in our service by specific training, we investigated the nature of complaints and incidents and attributed these reports to the seven CanMEDS roles. The observation that a substantial part of the reports were related to the whole perioperative period, including locations outside the operating rooms emphasises that anaesthesiologists become a perioperative physician with responsibilities extending beyond the intraoperative period.
Consistent with our hypothesis, many complaints could be attributed to roles other than that of ‘medical expert’. One-third of all complaints were assigned to the role of ‘manager’. These complaints were often related to operation room planning. About 15% of the complaints were attributed to the role of ‘communicator’ concerning misinformation of patients, for example, discrepancy between anaesthetic techniques as explained during the preoperative assessment and the actually applied technique during the intraoperative phase.
Reports addressing complaints about the roles of ‘medical expertise’ or ‘manager’ indicated that lack of communication about the mishap with the patient was one of the reasons to complain. We got the impression that patients often blamed doctors not for mistakes, but for a lack of openness or willingness to explain what happened. Patients taking legal action afterwards often aim for more honesty, an appreciation of the severity of the trauma they have suffered, and assurances that lessons have been learnt from their experiences.19 Physicians who inform patients adequately about what they have to expect and check their understanding are less likely to receive claims.20
Like complaints, incident reports were attributed mainly to roles other than the role of ‘medical expert’ and were often related to medical complications and medication failure. A substantial part of the incidents ascribed to the role of ‘manager’ were incidents of improper functioning of medical instruments. A substantial part of the incidents could be attributed to the role of ‘collaborator’ and concerned communication problems between professionals, mainly in the preoperative period. There were no complaints or incident reports categorised in the roles of ‘health advocate’ and ‘scholar’, which might be explained by the fact that these roles mostly do not concern individual patients or particular problems. Our study indicates that not only deficiencies in the role of medical expert, but also in the roles of managing, communication, collaboration and professional behaviour contribute significantly to the occurrence of complaints and incidents in anaesthesia.
The study database included all complaints and incident reports without exceptions admitted to the Anaesthesiology Department in the study period. Due to underreporting, our database may, however, not necessarily represent the cross-section of all adverse outcomes.21 This study bias may, therefore, have limited the impact of complaints and incident reports on organisational and healthcare quality improvement. Future implementation of a digital complaint and incident reporting system, standardisation of terminology and coding and promotion of a safe working environment may reduce these limitations.22,23 Our results also show that not all complaints and incident reports that were addressed to anaesthesia service involved an anaesthesiologist or anaesthesia nurse. Specific operating room-related management aspects like planning of postponement of surgery are perceived as part of anaesthesia service, though they should be attributed to the Department of Surgery.
In summary, complaints and incident reports related to anaesthesia service are foremost attributed to nontechnical skills and can be attributed to the five CanMEDS roles ‘medical expert’, ‘manager’, ‘professional’, ‘communicator’ and ‘collaborator’. Our study shows that the role of medical manager is equally significant as the role of medical expert in anaesthesia service and implies that nontechnical roles should get more attention in postgraduate training programmes of anaesthesiologists. The CanMEDS system has indeed been implemented in the Dutch anaesthesiology specialist competency training in order to shift the focus from the role of medical expert and professional to a broader approach addressing the roles as manager, collaborator and communicator. Moreover, societal changes and emphasis on perioperative patient safety contribute towards a change in the professional attitude of anaesthesiologists with increasing emphasis on nontechnical skills. Our results underline the importance of the roles as manager and collaborator in the training programmes of anaesthesiologists, not only to improve patient safety, but also to improve satisfaction of patients and colleagues with anaesthesia services.
1 Kohn LT, Corrigan JM, Donaldson MS. To err is human: building a safer health system.
Washington DC: National Academy Press; 1999. http://www.nap.edu/books/0309068371/html/
[Accessed December 2002].
2 Vincent C, Neale G, Woloshynowych M. Adverse events in British hospitals: preliminary retrospective record review. BMJ 2001; 322:517–519.
3 Brennan T, Leape L, Laird N, et al
. Incidence of adverse event and negligence in hospitalized patients. Results of the Harvard Medical
Practice study I. N Engl J Med 1991; 324:370–376.
4 Davis P, Lay YR, Briant R, et al
. Adverse events in New Zealand public hospitals I: occurrence and impact. N Z Med J 2002; 115:U271.
5 Forster A, Asmis T, Clark H, et al
. Ottawa hospital patient safety study: incidence and timing of adverse events in patients admitted to a Canadian teaching hospital. Can Med Assoc J 2004; 170:1235–1240.
6 Baker G, Norton P, Flintof V, et al
. The Canadian Adverse Events study: the incidence of adverse events among hospital patients in Canada. Can Med Assoc J 2004; 170:1678–1686.
7 Schioler T, Lipczak H, Pederson B, et al
. Incidence of adverse events in hospitals. A retrospective study of medical
records. Ugeskr Laeger 2001; 163:5370–5378.
8 Leape LL, Lawthers AG, Brennan TA, Johnson WG. Preventing medical
injury. Qual Rev Bull 1993; 19:144–149.
9 Thomas EJ, Orav EJ, Brennan TA. Hospital ownership and preventable adverse events. Int J Health Serv 2000; 30:739–743.
10 Thomas EJ, Studdert DM, Burstin HR, et al
. Incidence and types of adverse events and negligent care in Utah and Colorado in 1992. Med Care 2000; 38:261–271.
11 Zegers M, de Bruijne MC, Wagner C, et al
. Adverse events and potentially preventable deaths in Dutch hospitals: results of a retrospective patient record review study. Qual Saf Healthcare 2009; 18:297–302.
12 Fletcher GC, McGeorge P, Flin RH, et al
. The role of nontechnical skills in anaesthesia
: a review of current literature. Br J Anaesth 2002; 88:418–429.
13 Frank J, Jabbour M, Tugwell P. Skills for the New Millennium: report of the Societal Needs Working Group, CanMEDS 2000 Project. Ann R Coll Physicians Surg Can 1996; 29:206–216.
14 Kearney RA. Defining professionalism in anaesthesiology. Med Educ 2005; 39:769–776.
15 Kopp VJ, Shafer A. Anesthesiologists and perioperative communication. Anesthesiology 2000; 93:549–555.
16 Cooper JB, Newbower RS, Long CD, McPeek B. Preventable anesthesia mishaps: a study of human factors. Anesthesiology 1978; 49:399–406.
17 Cooper JB, Newbower RS, Kitz FJ. An analysis of major errors and equipment failures in anesthesia management: considerations for prevention and detection. Anesthesiology 1984; 60:34–42.
18 Gaba DM. Human error in anesthetic mishaps. Int Anesth Clin 1989; 27:137–147.
19 Vincent C, Young M, Philips A. Why do people sue doctors? A study of patients and relatives taking legal action. Lancet 1994; 343:1609–1613.
20 Levinson W, Roter DL, Mullooly JP, et al
. Physician-patient communication. The relationship with malpractice claims among primary care physicians and surgeons. JAMA 1997; 277:553–559.
21 Beckman HB, Markakis KM, Suchman AL, Frankel RM. The doctor-patient relationship and malpractice. Lessons from plaintiff depositions. Arch Intern Med 1995; 154:1365–1370.
22 Burkoski V. Identifying risk: the limitations of incident reporting. Can Nurse 2007; 103:12–14.
23 Kreckler S, Catchpole K, McCulloch P, Handa A. Factors influencing incident reporting in surgical care. Qual Saf Healthcare 2009; 18:116–120.