310
Increased numbers of allegations of negligence and public expectations for solu-
tions have created a pressure to enforce the prevention of surgical error [ 3 ]. The
medical profession has responded to these pressures by placing greater emphasis on
system-wide analyses of quality assurance and quality improvement strategies [ 4 ,
5 ]. These approaches are similar to those used in engineering and aviation, where
advances have been made to reduce human factor contributions to error in the work-
place [ 6 , 7 ]. In surgery, the study of error has largely focused on “systems” causes,
with little attention directed toward identifying causes for individual surgeon error
or failures of self-regulation.
One NEJM study on adverse events in hospitalized patients notes that “unfortu-
nate decisions and actions” occurring during care were a leading cause of death and
disability [ 8 ]. Subsequent research showed that many of these decisions and actions
were actual errors [ 9 ]. Definitions of “medical error” have been highly variable,
making it hard to study error in epidemiology [ 10 ] with the additional issue that the
term carries negative connotations of failure and blame. In recent literature, medical
error has been defined as an “act or omission that leads to an unanticipated, undesir-
able outcome or to substantial potential for such an outcome” [ 11 ]. This will be the
definition of error used in this review.
Adverse patient events are inevitable and common, yet many surgeons are poorly
prepared for the emotional reactions they experience when they occur. To date, these
reactions are widely considered “part of the job” of being a surgeon, a consequence of
being a member of the profession. Although, if asked, most surgeons would acknowl-
edge they experience a negative emotional reaction following an adverse event, the
nature and impact of these events in surgical education are not well articulated. Surgical
culture typically does not encourage open acknowledgment of these emotions; thus,
surgeons would be unlikely to volunteer such information without direct probing into
their experiences. In fact, it is quite possible that surgical culture itself may be a major
contributor to the negative reactions we experience. With increased rates of burnout,
suicide, divorce, and attrition among surgeons, it is important that we begin to under-
stand what contributes to these reactions. Acknowledging and exploring these questions
may better prepare the future generation of surgeons and keep our profession healthy.
How do surgeons react to error or patient complications? What factors affect
these reactions, and how do these reactions affect future performance? Perhaps the
best phenomenological description of these reactions has been provided by Paget
[ 12 ]. Actions themselves are not distinctly seen as right or wrong, but instead they
become right or wrong, in retrospect, in a process Paget calls “complex sorrow.” Her
work suggests that reactions to medical error are not as simple as once thought. An
example of the ongoing interplay between error and practice was highlighted in one
study exploring surgeons’ reactions to unexpected outcomes or situations. Results
indicate that surgeons’ reactions to errors affect subsequent decision- making and
judgment, and further research is clearly needed if we are to properly understand the
association between the two [ 13 ].
This chapter will shed light on recent work that explored surgeons’ reactions to
adverse events. Several psychological theories are proposed, and ways they might
M.H. Mobilio and C.-a. Moulton