Responses to errors and adverse events: The need for a systems approach in otolaryngology

Objectives/Hypothesis: To report otolaryngologists' reactions to errors and adverse events and determine if temporal changes in physician efforts to assume responsibility; ameliorate patients' conditions; or change personal, group-wide, or hospital practices have occurred. Study Design: Mixed-methods analysis of survey entries detailing responses to errors and adverse events. Methods: Members of the American Academy of Otolaryngology–Head and Neck Surgery were asked to report errors or adverse events. Responses to open- and closed-ended questions from a similar, previously distributed, anonymous national survey were included for analysis. Responses were enumerated and reported descriptively and then analyzed by reviewers using an interpretive phenomenological approach. Responses were compared to those from an identical survey distributed a decade prior. Results: Otolaryngologists reported 226 adverse events. Responsibility was attributed to the physician surveyed in 74 cases (32.0%), to ancillary staff in 58 cases (25.1%), to consulting physicians in 24 cases (10.4%), and to trainees in 16 cases (6.9%). The undertaking of corrective actions was reported by 175 physicians (75.8%). These events led to changes in personal, group/departmental, and hospital practice in 78 (33.8%), 37 (16.0%), and 11 (4.8%) cases, respectively. Conclusion: Following errors and adverse events, otolaryngologists continue to employ corrective actions to ameliorate harm. Responses are directed toward ameliorating the patient injury and also toward efforts to change personal practice and/or improve systems performance. Efforts to change personal practice are much more common than efforts to improve systems. Education about systems-based change represents a large opportunity for improvement in our specialty. Level of Evidence: N/A Laryngoscope, 126:1999–2002, 2016.