Ethical and legal responsibilities, negligence as the primary cause of error, and the importance of clinical records
Those interviewed regarding ethical and legal responsibilities described that their main fear is the institutional repercussions (administrative liability), which could lead to possible dismissal, including the loss of their professional card (deontological liability). The members of the surgical team were unsure about the probability of a complaint going directly to the government authorities, especially in cases where a foreign body could have caused a permanent or temporary disability or even the death of the patient.
When a colleague commits an error, initially the person involved is held responsible for their mistake; then, the responsibility escalates to the immediate supervisor and then to human resources, going up to the authorities that should come depending on the type of problem. (Coded Voice [3:6]).
Well, the legal part is something extremely delicate, and it would imply the loss of our license to keep working. (Coded Voice [8:3]).
Negligence was the primary error mentioned by the members of the surgical team, especially the careless management of the patient because of misinformation and poor writing of medical records (MRs); eventually, MRs end up not being a reliable document when making decisions regarding the surgical protocol. Inexperience was also found to be related to emergency procedures, as well as poor management of personal problems as a cause of a possible miscounting of elements and instruments before, during, and after the surgical procedure.
There are several causes, ranging from poor patient preparation, patient misinformation, emergency procedures, poorly written medical records, and personal problems, that could lead to forgetfulness during a procedure. (Coded Voice [3:4]).
In relation to the clinical records as a conditioning element in the actions of the members of the surgical team and as evidence in a medical liability process aiming at proving a medical malpractice, it was found that MRs do not describe the error, pointing at ignorance of the norm or failure to comply with it as the main possible reason. Some members of the surgical team described the low institutional requirement for reading MRs, recognizing the high probability of making an error (actual malpractice). In addition to these elements, there are other factors such as emergency surgery, shift changes, work monotony and inappropriate application of the checklist, work stress, and the normalization of errors (daily errors), among others.
I think emergency surgeries are the main reason, as well as shift changes that are not delivered in a correct way. (Coded Voice [15:4]).
Monotony, insecurity at the time of starting the procedure, stress from the doctor, some emotional problems. (Coded Voice [16:2]).
Complicity and bioethical principles
The interviewees were conflicted between the principles of respect and justice, which makes it their medical duty to report events or actions (of their own or colleagues) that put a patient’s life at risk. In other words, professional secrecy should not be confused with complicity. Conversely, the principle of justice holds the medical professional responsible for maintaining silence and not reporting an error caused by a team member, which must be reported and described in the clinical records in detail.
I would not report it because everyone should know his or her own responsibilities. (Coded Voice [7:5]).
Well, in this case, since we are talking about a colleague, I personally would not report it, but I would talk to the colleague and let them be the one to report the case to the immediate supervisor. (Coded Voice [17:5]).
Surgical awareness in preventing medical errors concerning RSIs
Surgical awareness was reflected in the conscientiousness and thoughtfulness of the actions of the members of the surgical team as they made corrective actions to avoid errors. They recognized that human nature is influenced by factors that can lead to errors such as leaving a foreign body in the patient body or even failing to report it.
In our medical practice, we are still human and we can make mistakes at any moment, but if we are aware and we realize in time that we are doing a bad procedure, we must verify, count, and alert all personnel to reduce risks and provide greater patient safety. (Coded Voice [3:3]).
First, you try to talk to your colleague and tell them what happened to try to find a solution, and if you do not find a solution, you report it to your supervisor. (Coded Voice [4:5]).
If the error happens during the surgical procedure and you realize it immediately, you must inform the physician about the problem; if you realize after the surgical procedure, you must also inform the physician and request the corresponding radiological studies to verify the existence of the foreign body. (Coded Voice [15:3]).
Conflict about responsibility related to their professional ethics
There is a conflict among medical professionals about liabilities in the lack of surgical awareness related to the measures taken to avoid causing harm to patients and thus avoiding being punished, even when they may be accused of complicity. That is, they do not prioritize the welfare of the patient but their own interest, and this is caused by the fear of being involved in something similar to the presence of an RSI. They may even come to believe that the responsibility is individual, which is not far from reality. It should be stressed that, as the members of a surgical team, they are all part of the team; therefore, they have a common goal, which is the safety and quality of the surgical procedure performed for the welfare of the patient. In this context, it is fundamental to point out the importance of taking into account the attitude toward responsibility that health care professionals have with their work in practice, in addition to the possible psychological damages of doubting if it was really a single foreign body, generating anxiety, and thus affecting the recovery of the surgical patient.
The main fear is the harm we will cause to the patient and the negative effects that malpractice will have on the patient, as well as the legal implications. (Coded Voice [3:8]).
That the patient suffers from complications or dies because, if something happens to them, it can also affect me. (Coded Voice [6:3]).
Another important element is the fact that members of the surgical team confused social values with professional ethics. They considered that ethics are innate to human nature, meaning that we are somehow born with it or we bring ethics from home, and therefore, it does not need to be taught at the professional level. It should be noted that social values help us generate different affective bonds, as they are taught in our first circle of socialization, such as family;, humans build their own criteria through the years, and therefore, they know the good and bad within the framework of professional ethics.
It is of utmost importance to consider ethical principles in our profession. They should be embodied in our lives. We learn them at home and they mature as we grow. (Coded Voice [3:1]).
I do not think so, as we all learn those principles at home. (Coded Voice [17:2]).
Education, an important element in recognizing medical errors
Education was found to be related to professional ethics. The members of the surgical team recognized that education allows them to recognize and reflect on the differences between real and apparent malpractices.
Ethics is what makes us. If professionals do not have ethics, they are not able to behave responsibly as such and they will make multiple errors in their practice, where patients will be the most harmed party. (Coded Voice [11:2]).
Yes, as when professionals are trained, they are taught the principles; then, they will be qualified professionals who will always act by the principles of good faith and efficiency to provide a service within the best conditions. (Coded Voice [15:2]).
Important principles to avoid medical errors, especially forgetting a foreign body in patient bodies
Most of the members of the surgical team described responsibility as an important principle to fully comply with the processes and protocols that safeguard patient safety. Other important principles are as follows: caution and confidentiality in not disclosing the patient's clinical or personal information to personnel not directly involved in the surgical process; entrusting the team to have everything prepared according to the conditions of the patient and institution, ultimately giving peace of mind to everyone involved; self-discipline to continue educating themselves to become more and more aware of their responsibility to be able to predict and prevent risks and complications inherent to an RSI in the patient's body.
In our medical practice, we are still human and we can make mistakes at any moment, but if we are aware and we realize in time that we are doing a bad procedure, we must verify, count, and alert all personnel to reduce risks and provide greater patient safety. (Coded Voice [3:3]).
As professionals, our work is all about ethics; a professional without ethics is not fit to practice the profession as such, and a great deal of responsibility is required in this field. (Coded Voice [11:1]).
Principles make us qualified professionals who will always act by the principles of good faith and efficiency to provide a service within the best conditions. (Coded Voice [15:2]).