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PSNet: Patient Safety Network
Journal Article

Error or "act of God"? A study of patients' and operating room team members' perceptions of error definition, reporting, and disclosure.

Espin S, Levinson W, Regehr G, et al. Surgery. 2006;139:6-14.

This study discovered both similarities and differences in the way surgeons, nurses, anesthesiologists, and patients responded to four scripted clinical error scenarios. Findings suggested that all groups incorporated a negative outcome or a deviation from standard of practice into their error definition rather than analyzing the event independent of those factors. In addition, noted differences existed between patients who supported reporting for all negative events and nurses who believed in selective reporting. Similarly, persistent gaps existed between the full disclosure patients expect and the partial disclosure health professionals believe should occur. While the study represents a small sample size from two tertiary institutions, it does emphasize the importance of a safety culture and the need to redefine errors as opportunities for learning and improvement rather than individual or isolated events.