Barriers to Adverse Event and Error Reporting in AnesthesiaA2012Heard... · search on physicians’ perceived barriers to reporting is further limited because results are reported

Barriers to Adverse Event and Error Reportingin AnesthesiaGaylene C. Heard, MBBS, FANZCA, MHumanFact,* Penelope M. Sanderson, PhD, FASSA,†and Rowan D. Thomas, MBBS, FANZCA, MPH*

BACKGROUND: Although anesthesiologists are leaders in patient safety, there has been littleresearch on factors affecting their reporting of adverse events and errors. First, we explored theattitudinal/emotional factors influencing reporting of an unspecified adverse event caused byerror. Second, we used a between-groups study design to ask whether there are differentperceived barriers to reporting a case of anaphylaxis caused by an error compared withanaphylaxis not caused by error. Finally, we examined strategies that anesthesiologists believewould facilitate reporting. Where possible, we contrasted our results with published findings fromother physician groups.METHODS: An anonymous, self-administered, mailed survey was conducted of 629 consultantanesthesiologists and 263 anesthesiology residents on the mailing list of the Australian andNew Zealand College of Anaesthetists in Victoria, Australia. Participants were randomized into“Error” versus “No Error” groups for the specified anaphylaxis adverse event section of thesurvey. Data were analyzed using nonparametric descriptive and inferential tests.RESULTS: There were 433 usable returned surveys, a usable response rate of 49%. First, therewas only 1 of 13 statements on attitudinal/emotional factors that influenced reporting of anunspecified adverse event caused by error with which more anesthesiologists agreed/stronglyagreed than disagreed/strongly disagreed: “Doctors who make errors are blamed by theircolleagues.” Second, when an error rather than no error had caused anaphylaxis, participantswere more likely to agree/strongly agree that 6 statements about litigation, getting into trouble,disciplinary action, being blamed, unsupportive colleagues, and not wanting the case discussedin meetings, were perceived as reporting barriers. Finally, the most favored assistive strategiesfor reporting were generalized deidentified feedback about adverse event and error reports, rolemodels such as senior colleagues who openly encourage reporting, and legislated protection ofreports from legal discoverability.CONCLUSION: The majority of anesthesiologists in our study did not agree that theattitudinal/emotional barriers surveyed would influence reporting of an unspecified adverseevent caused by error, with the exception of the barrier of being concerned about blame bycolleagues. The probable influence of 6 perceived barriers to reporting a specified adverse eventof anaphylaxis differed with the presence or absence of error. Anesthesiologists in our studysupported assistive reporting strategies. There seem to be some differences between ourresults and previously published research for other physician groups. (Anesth Analg 2012;114:604–14)

Anesthesiologists have been acknowledged as lead-ers in patient safety strategies,1 yet there has beenvery little research on barriers they perceive to

reporting adverse events and errors. Accurate reporting oferrors is considered to be fundamental to improving pa-tient safety2,3 because “you can’t fix what you don’t knowabout.”4 Underreporting in health care is evidenced byexpert opinion and past research2,3,5–8 and by the improvedreporting behavior that occurs when reporting systems areintroduced and supported.9,10

Reporting and learning are 2 critical features of aneffective safety culture.11 Counting adverse events anderrors for the sake of it contributes little unless the data areanalyzed and used to create safer systems.2,3,12 When errorswith no adverse outcomes are reported, “free lessons” areprovided by analyzing what strategies were used to catchincipient errors or mitigate their effects before harm oc-curred.13 Potential benefits from a culture of error disclo-sure and open discussion include improved professionallearning and better patient outcomes from higher qualitycare, increased trust between patients and staff, less litiga-tion, and a more realistic view by patients and staff ofmedicine’s limitations.14

The patient safety movement promotes reporting oferrors but this contrasts with expert opinion that medicinehas a traditional “code of silence”14 around errors. Blameand shame15–17 contribute to underreporting. Higher re-porting rates are positively correlated with independentlydefined measures of a safety culture, including lack ofblame and punishment and fair treatment for staff involvedin errors or incidents.10

The 10 most frequently cited barriers to medical errordisclosure are professional repercussions of disclosure,

From the *Department of Anaesthesia, St. Vincent’s Hospital, Melbourne,Victoria; and †Schools of Psychology, Information Technology andElectrical Engineering, and Medicine, The University of Queensland,Brisbane, Australia.

Accepted for publication May 13, 2011.

Funding: Self-funded by first author.

The authors declare no conflicts of interest.

Reprints will not be available from the authors.

Address correspondence to Gaylene C. Heard, MBBS, FANZCA,MHumanFact, Department of Anaesthesia, St. Vincent’s Hospital, PO Box2900, Fitzroy, Melbourne, Victoria, Australia 3065. Address e-mail [email protected].

Copyright © 2012 International Anesthesia Research SocietyDOI: 10.1213/ANE.0b013e31822649e8

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legal liability, blame, lack of confidentiality, negative pa-tient or family reaction, humiliation, perfectionism, guilt,lack of anonymity, and the absence of a supportive forumfor disclosure.18 Uncertainty about definitions of errorsand adverse events, lack of time to report, and knowingneither what nor how to report are further barriers.2,19,20

Strategies to improve reporting include providing fasterand improved feedback,2 education in reportable eventrecognition,2 user-friendly paper-based and computer-ized systems,21,22 and payment for reports.23

There has been little research specifically examiningwhether perceived barriers to reporting an adverse eventdiffer based on whether or not that event was caused by anerror. Unfortunately, the available previous survey re-search on physicians’ perceived barriers to reporting isfurther limited because results are reported for mixedgroups of physicians and nurses19,24 and fewer itemsspecifically probe emotional barriers to reporting.19,20,24

In a previous South Australian survey of physicians, 14%agreed or strongly agreed that “My coworkers may beunsupportive” and 21% agreed or strongly agreed that “Iam worried about litigation” were perceived barriers toincident reporting.20 In a United States survey of physi-cians’ perceived barriers to error reporting, “Not know-ing the usefulness of the report” and “Thinking thatreporting has little contribution for improvement ofquality of care” were among the top 6 of 17 barriers.19

In our study, the attitudes and perceived barriers ofanesthesiologists to reporting adverse events and errors wereexplored. First, we asked whether anesthesiologists in oursample agreed or disagreed with the attitudinal/emotionalfactors we listed that may influence whether an adverse eventcaused by an error will be reported. Second, we askedwhether there is a difference in perceived barriers to reportinga specified adverse event of anaphylaxis caused by an errorcompared with no error. Third, we asked which assistivestrategies our participants thought could improve reporting.In our Discussion, we illustrate how our results differ frompreviously published surveys of perceived barriers to report-ing in other physician groups.

METHODSParticipantsEthics approval was obtained from The University ofQueensland. In accordance with its Ethics Guidelines, awaiver was granted for the need for individual signed par-ticipant consent because the study involved an anonymousmailed survey with minimal risk to participants. The Partici-pant Information Sheet, mailed to potential participants in thesurvey, explained that participation was voluntary. The Aus-tralian and New Zealand College of Anaesthetists (ANZCA)Trials Group provided gatekeeper permission to send thesurvey to anesthesiologists and anesthesiologist trainees onits mailing list.

We conducted an anonymous, self-administered surveyof 629 consultant anesthesiologists and 263 anesthesiologyresidents on the ANZCA mailing list in the state of Victoria,Australia. The participant sample group is 84% of allconsultant anesthesiologists and 100% of anesthesiologyresidents in Victoria.

MaterialsParticipants received a mailed survey package consisting ofa covering letter, Participant Information Sheet, question-naire, and a stamped, addressed reply envelope. Afollow-up reminder was e-mailed.

The questionnaire had 5 sections: 3 sections listed state-ments to be rated using a 5-point Likert scale ranging from“strongly agree” to “strongly disagree,” a fourth sectionhad questions on demographic characteristics, and a fifthsection was for free text comments. The survey packageswere identical except for section 2.

Section 1 of the QuestionnaireSection 1 specifically explored attitudinal and emotionalfactors that could influence whether an (unspecified) ad-verse event caused by an error would be reported. Becauseof the lack of published survey items on these attitudinaland emotional factors, the construction of the survey itemsfor section 1 was informed by a literature review as part ofa master’s thesis, and was based on a published, empiri-cally derived taxonomy of factors impeding the willingnessof physicians to disclose medical errors.18 Section 1 had 13survey items, with 10 items based on the domain ofattitudinal barriers in the taxonomy18 and 3 based on thedomain of fears/anxieties barriers.18

Section 2 of the QuestionnaireSection 2 of the survey had a between-groups design. Itcovered barriers to reporting an adverse event of anaphy-laxis, with or without an error as its cause. This sectioncontained a case scenario: “You are anesthetizing a 32-year-old woman for an elective laparoscopic cholecystectomy.You give the patient an IV antibiotic after induction and thepatient develops a very severe anaphylaxis, which you treatappropriately. The surgery is postponed and the patient,who remains intubated, is transferred to ICU for furthermonitoring and treatment. She makes a full recovery.”There were 2 different endings to the scenario:

• For the group No Error: “The patient had no history ofdrug allergy.”

• For the group Error: “You realize afterward you havegiven the patient that particular antibiotic in error,because the patient had told you preoperatively thatshe was allergic to it and you had written this on theanesthetic chart preoperatively.”

There were no features on the surveys to distinguish thegroup No Error from the group Error surveys, apart fromthe different endings to the scenario. There were 17statements to rate as barriers to reporting the anaphy-laxis, with 14 of these statements either the same as orsimilar to previously published survey statements.20,24

For example, we changed statement wording such as “onthe ward”20,24 to “at work” to suit our anesthesiologyparticipants, and preferred the word “colleagues”24

rather than “coworkers.”20 Three statements had beenmore substantially altered.

Section 3 of the QuestionnaireSection 3 covered strategies to improve reporting of ad-verse events and errors, with 17 statements on factors that

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would “help you to report adverse events and errors.”These survey items were constructed based on literaturereview of strategies shown to increase reporting such asfeedback,2 education,2 user-friendly systems,21,22 payment,23

and on the perceived barriers to reporting that physiciansthought would be modifiable to increase reporting.19

Section 4 of the QuestionnaireSection 4 covered demographic characteristics, with ques-tions on type of practice (public or private practice), yearsof anesthesia experience, age group, location (capital city orregional/rural), and gender.

Section 5 of the QuestionnaireThis section was for participants’ free text comments aboutthe survey or about reporting adverse events and errors.

ProcedureThe survey was piloted on 20 anesthesiologists and 5anesthesia residents to examine the usability of the survey,using contextual inquiry and modified cognitive walk-through techniques. Minor changes were subsequentlymade to the wording of the survey instructions and to 3survey items. The survey packages were prepared into 2separate groups, group No Error and group Error, by theresearchers and packed in random order for mailing usinga randomization table.25 The survey packages were ad-dressed and mailed by ANZCA. The researchers did nothave access to participants’ names and addresses. Afollow-up reminder by e-mail was sent to participants byANZCA 2 weeks after the initial mailing.

Data CollationEach returned survey was given a unique identificationnumber and an “NE” or an “E” depending whether it wasin group No Error or group Error. Missing data weretreated as null. Data were entered into an Excel™ spread-sheet (Microsoft, Redmond, WA).

Statistical AnalysisThe data obtained from the Likert scales were treated as ordinaldata, and nonparametric inferential tests were used. A 2(groups) � c (categories) �2 test was used to compare thedemographic characteristics of group No Error and group Error.A series of 2 (groups) � 5 (levels of agreement) Wilcoxon-Mann-Whitney (WMW) tests was used to compare the responses ofparticipants in group No Error and group Error for section 2. Aseries of r (demographic categories) � c (levels of agreement)Kruskal-Wallis tests was used to examine the effects of demo-graphic characteristics on participants’ responses in sections 1 to3. Post hoc analyses of statistically significant demographicinfluences were performed using 2 � c WMW tests. To maintainthe family-wise type I error rate at 0.05, all raw P values from theKruskal-Wallis tests and WMW tests were adjusted for theeffects of multiple comparisons using the Ryan-Holm step-downprocedure,26–29 with raw P values arranged in ascending orderand sequentially adjusted until all hypotheses were tested oruntil the adjusted P value was �0.05. Data were analyzed usingStata version 10 (StataCorp, College Station, TX). A P value of�0.05 was considered statistically significant.

RESULTSThe usable survey response rate was 52% for consultant anes-thesiologists and 39% for anesthesia residents, with an overallusable response rate of 49%. The usable response rate for womenwas 46% and for men 49%. Two participants did not completesection 2 but completed the other sections. Twenty other surveyshad some missing data. Participants worked mainly in a capitalcity and in public hospital practice (Table 1). For section 2, therewere 214 participants in group No Error and 217 partici-pants in group Error, and as expected from the randomiza-tion process,30 there were no statistically significant differ-ences between their demographic characteristics.

Section 1The only statement with which more participants agreed orstrongly agreed than disagreed or strongly disagreed was“Doctors who make errors are blamed by their colleagues,”with 46% (confidence interval [CI], 42%–51%) agreeing orstrongly agreeing, 26% (CI, 22%–30%) disagreeing orstrongly disagreeing, and 27% (CI, 23%–32%) neutral(Table 2). There were no statistically significant demo-graphic influences on responses.

Section 2Participants in group Error were more likely to agree orstrongly agree than those in group No Error that 6 of the 17statements were barriers to reporting the anaphylaxis (Fig.1, Tables 3 and 4). The 6 statements were:

• I am worried about litigation.• I don’t want to get into trouble.• My colleagues may be unsupportive.

Table 1. Demographic Characteristicsof Participantsa

Characteristic Frequency (n) PercentageAge group (y)

21–30 42 9.731–40 156 36.141–50 111 25.751–60 89 20.661–70 33 7.7�71 1 0.2

GenderFemale 131 30.3Male 301 69.7

Practice typeMostly private 121 28.0Mostly public 251 58.1Public/private 59 13.7Other 1 0.2

Work locationCapital city 360 83.3Regional/rural 69 16.0Mix capital/regional 2 0.5Overseas 1 0.2

Years of experience�20b 114 26.510–20b 84 19.5�10b 129 29.9Anesthesia resident 100 23.2Prevocational resident 3 0.7Retired 1 0.2

a One participant did not answer any demographic questions and anotherparticipant answered all questions except years of experience.b Consultant anesthesiologist.

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• I am worried about disciplinary action.• I may be blamed unfairly for the event.• I do not want the case discussed in meetings.

For the other 11 statements for which there were nostatistically significant differences between groups Errorand No Error (Table 3), at least 68% (lowest confidencelimit) of participants disagreed or strongly disagreed withthe following statements:

• Adverse event reporting makes little contribution toquality of care (93% disagree/strongly disagree; CI,90%–95%).

• I don’t know whose responsibility it is to make a report(86% disagree/strongly disagree; CI, 83%–90%).

• A good outcome of the case makes reporting unneces-sary (86% disagree/strongly disagree; CI, 83%–90%).

• I do not know which adverse events should be reported(73% disagree/strongly disagree; CI, 68%–77%).

Demographic Influences on Response to Section 2Anesthesia residents in group No Error agreed or stronglyagreed more with “I am worried about disciplinary action”than did consultant anesthesiologists (Table 5). Anesthesiaresidents in group Error agreed or strongly agreed morewith “I do not know which adverse events should bereported” than did consultant anesthesiologists (Table 5).

Section 3Section 3 investigated strategies to improve reporting ofadverse events and errors. More than 75% (lower confi-dence limit) of participants agreed or strongly agreed with

7 assistive strategies about feedback, role models, legislatedprotection, ability to report anonymously, and clear guide-lines (Table 6). The only strategy with which the majority ofparticipants disagreed or strongly disagreed was “Paymentfor time taken to report.”

Demographic Influences on Responses to Section 3Of note, anesthesia residents were more likely to agree orstrongly agree than anesthesiologists in practice as consul-tants for �20 years, or those in practice as consultants for 10to 20 years, with the strategy “Payment for time taken toreport” (Table 7). Further analysis using age groupsshowed that 9% (CI, 0%–19%) of those aged 61 to 70 yearscompared with 41% (CI, 26%–57%) of those aged youngerthan 30 years agreed/strongly agreed with “Payment fortime taken to report.”

DISCUSSIONSection 1: Attitudinal and Emotional BarriersThe majority of the anesthesiologists surveyed did notagree with the attitudinal and emotional factors we exam-ined. Direct comparisons with other physician groups forthe emotional and attitudinal barriers explored in section 1are difficult because of the lack of previously publishedsurvey research using these items.

The traditional “perfectibility model”31,32 of errorprevention is a barrier to reporting.18 The “perfectibilitymodel” for error prevention is based on beliefs that

Table 2. Section 1: Attitudinal and Emotional Factors Influencing Reporting an Unspecified Adverse EventCaused by an Error

Statement Strongly agree Agree Neutral Disagree Strongly disagreeI would protect my self-interests

ahead of the interests of thepatient if I could, e.g., byhiding or denying an error.

0.7% (0.0–1.5) 4.4% (2.5–6.4) 7.7% (5.1–10.2) 56.3% (51.6–61.0) 30.9% (26.5–35.3)

Competition with my peers wouldprevent me from disclosing anerror.

0.2% (0.0–0.7) 7.7% (5.1–10.2) 10.9% (8.0–13.9) 56.3% (51.6–61.0) 24.9% (20.8–29.0)

If a doctor is careful enough heor she will not make an error.

1.4% (0.3–2.5) 10.6% (7.6–13.5) 9.4% (6.6–12.1) 51.4% (46.6–56.1) 27.2% (23.0–31.5)

It would affect my identity as adoctor to admit to an error.

0.5% (0.0–1.1) 9.3% (6.5–12.1) 13.5% (10.3–16.8) 60.6% (56.0–65.2) 16.1% (12.6–19.6)

Others don’t need to know abouterrors I have made.

0.5% (0.0–1.1) 11.7% (8.6–14.8) 19.2% (15.5–23.0) 55.3% (50.5–60.0) 13.3% (10.1–16.6)

Disclosing an error, if you don’thave to, is an optional act ofheroism.

1.2% (0.1–2.1) 12.3% (9.2–15.5) 19.1% (15.4–22.8) 50.8% (46.1–55.6) 16.6% (13.0–20.1)

I would cover up an error I hadmade if I could.

0.2% (0.0–0.7) 9.3% (6.6–12.1) 23.6% (19.5–27.6) 52.2% (47.5–57.0) 14.7% (11.3–18.0)

If I admit to an error I will feellike a failure.

1.9% (0.6–3.1) 19.1% (15.3–22.8) 16.0% (12.6–19.5) 50.2% (45.5–55.0) 12.8% (9.6–16.0)

It would affect my self-esteem toadmit to an error.

0.9% (0.0–1.8) 28.2% (23.9–32.4) 16.7% (13.2–20.3) 42.3% (37.6–47.0) 11.9% (8.8–15.0)

Doctors who make errors arehumiliated by their colleagues.

2.6% (1.1–4.1) 15.2% (11.8–18.6) 27.8% (23.3–31.8) 46.0% (41.3–50.8) 8.4% (5.8–11.1)

Medicine has a culture of silencewhere errors are not talkedabout.

6.1% (3.8–8.4) 30.4% (26.1–34.9) 23.0% (18.9–26.9) 37.5% (32.9–42.1) 3.0% (1.4–4.7)

Doctors who make errors areblamed by their colleagues.

3.3% (1.6–5.0) 43.1% (38.3–47.8) 27.5% (23.0–31.5) 25.4% (21.3–29.6) 0.7% (0.0–1.5)

Doctors should not make errors. 10.8% (7.8–13.7) 31.4% (27.0–35.8) 14.0% (10.7–17.3) 28.1% (23.8–32.4) 15.7% (12.2–19.2)

Data are presented as percentage with confidence interval.


physicians are capable of and should provide error-freepractice, with anything less being unacceptable.31,32 Tra-ditionally, physicians have been socialized throughouttheir training to strive for error-free practice.31,32 In ourstudy, 79% (CI, 75%– 83%) disagreed/strongly disagreedwith the statement “If a doctor is careful enough he orshe will not make an error,” suggesting that the anesthe-siologists in the sample do not agree with this aspect of

the perfectibility model. This may reflect education ofanesthesiologists about human performance and theinevitability of error. However, at a more personal level,21% (CI, 17%–25%) of our sample agreed/stronglyagreed, “If I admit to an error I will feel like a failure”and 29% (CI, 25%–33%) agreed/strongly agreed, “Itwould affect my self-esteem to admit to an error.” Errorsare a normal feature of human performance33 and human

Figure 1. Frequency of responses to section 2 statements for which there was a statistically significant difference between responses forgroup No Error and group Error.



fallibility has been described, using an aviation context,as “like gravity, weather, and terrain, just another fore-seeable hazard”11 that requires robust preventative mea-sures at both individual and system levels.

The placing of self-interest before patient interests18 andallowing competition with peers to inhibit disclosure18 were notagreed with by the majority of our anesthesiologists. This con-trasts with expert opinion that the competitive environment of

Table 3. Section 2: Perceived Barriers to Reporting Anaphylaxis, Group No Error Versus Group Errora

Statement P� valueb Group Strongly agree Agree Neutral Disagree Strongly disagreeI am worried about

litigation.�0.0001 NE 4.7% (1.8–7.5) 26.6% (20.7–32.6) 9.8% (5.8–13.8) 37.4% (30.8–43.9) 21.5% (15.9–27.0)

E 12.9% (8.4–17.4) 44.7% (38.0–51.4) 17.5% (12.4–22.6) 19.4% (14.1–24.6) 5.5% (2.5–8.6)I don’t want to get

into trouble.�0.0001 NE 1.9% (0.0–3.7) 16.8% (11.8–21.9) 10.3% (6.2–14.4) 44.8% (38.1–51.6) 26.2% (20.2–32.1)

E 3.7% (1.2–6.2) 35.9% (29.5–42.4) 17.5% (12.4–22.6) 33.2% (26.9–39.5) 9.7% (5.7–13.6)My colleagues may be

unsupportive.�0.0001 NE 0.9% (0.0–2.2) 13.5% (8.9–18.2) 16.4% (11.4–21.3) 44.4% (37.7–51.1) 24.8% (18.9–30.6)

E 3.7% (1.2–6.2) 26.3% (20.4–32.2) 16.1% (11.2–21.1) 42.4% (35.8–49.0) 11.5% (7.2–15.8)I am worried about

disciplinary action.�0.0001 NE 0.5% (0.0–1.3) 8.9% (5.0–12.7) 11.2% (6.9–15.5) 53.7% (47.0–60.5) 25.7% (19.8–31.6)

E 4.2% (1.5–6.8) 18.4% (13.2–23.6) 17.0% (12.0–22.1) 49.3% (42.6–56.0) 11.1% (6.8–15.3)I may be blamed

unfairly for theevent.

0.002 NE 0.5% (0.0–1.4) 14.5% (9.7–19.2) 12.6% (8.1–17.1) 47.2% (40.4–53.9) 25.2% (19.4–31.1)E 1.4% (0.0–2.9) 20.3% (14.9–25.7) 18.0% (12.8–23.1) 49.3% (42.6–56.0) 11.0% (6.8–15.3)

I do not want thecase discussed inmeetings.

�0.0001 NE 0.5% (0.0–1.4) 3.3% (0.1–5.7) 6.6% (3.2–9.9) 52.4% (45.6–59.1) 37.2% (30.7–43.8)E 0.9% (0.0–2.2) 13.8% (9.1–18.5) 9.2% (5.3–13.1) 58.6% (51.9–65.1) 17.5% (12.4–22.6)

Adverse eventreporting makeslittle contribution toquality of care.

NS NE 0.9% (0.0–2.2) 1.4% (0.0–3.0) 5.2% (2.1–8.2) 49.6% (42.7–56.3) 42.9% (36.2–49.6)E 0.0% (0.0–0.0) 1.9% (0.0–3.6) 5.1% (2.1–8.0) 47.2% (40.5–53.9) 45.8% (39.1–52.5)

I don’t know whoseresponsibility it isto make a report.

NS NE 0.5% (0.0–1.4) 5.1% (2.1–8.1) 10.8% (6.5–14.9) 55.6% (48.9–62.3) 28.0% (22.0–34.1)E 0.0% (0.0–0.0) 2.8% (0.1–4.9) 8.3% (4.6–11.9) 59.4% (52.8–66.0) 29.5% (23.4–35.6)

A good outcome ofthe case makesreportingunnecessary.

NS NE 0.5% (0.0–1.3) 5.6% (2.5–8.7) 9.3% (5.4–13.3) 57.0% (50.3–63.7) 27.6% (21.5–33.6)E 0.5% (0.0–1.4) 2.3% (0.3–4.3) 9.2% (5.3–13.1) 59.0% (52.4–65.6) 29.0% (22.9–35.1)

I do not know whichadverse eventsshould be reported.

NS NE 0.5% (0.0–1.4) 21.9% (16.4–27.6) 8.9% (5.0–12.7) 48.6% (41.8–55.3) 20.1% (14.7–25.5)E 1.4% (0.0–2.9) 12.4% (8.0–16.9) 8.8% (5.0–12.5) 57.6% (51.0–64.2) 19.8% (14.5–25.2)

Even if I don’t give mydetails I’m worriedthey’ll track medown.

NS NE 1.9% (0.4–3.7) 7.9% (4.3–11.6) 22.4% (16.8–28.1) 47.2% (40.5–53.9) 20.6% (15.1–26.0)E 2.8% (0.6–4.9) 12.0% (7.6–16.4) 22.7% (17.0–28.3) 46.3% (39.6–53.0) 16.2% (11.2–21.1)

The forms take toolong to fill in and Ijust don’t havetime.

NS NE 1.4% (0.0–3.0) 26.2% (20.2–32.1) 22.9% (17.2–28.6) 39.2% (32.7–45.8) 10.3% (6.2–14.4)E 1.4% (0.0–2.9) 23.0% (17.4–28.7) 19.8% (14.5–25.2) 46.1% (39.4–52.8) 9.7% (5.7–13.6)

When I am busy atwork I forget tomake a report.

NS NE 2.3% (0.3–4.4) 37.4% (30.8–43.9) 10.8% (6.6–14.9) 37.4% (30.8–43.9) 12.1% (7.7–16.6)E 2.8% (0.5–5.0) 28.2% (22.2–34.3) 13.9% (9.2–18.5) 44.0% (37.3–50.6) 11.1% (6.9–15.3)

I don’t feel confidentthe information Iprovide will be keptconfidential.

NS NE 4.7% (1.8–7.5) 19.2% (13.8–24.5) 23.8% (18.1–29.6) 37.8% (31.3–44.4) 14.5% (9.7–19.2)E 5.5% (2.5–8.6) 25.0% (19.2–30.1) 24.1% (18.3–30.0) 35.7% (29.2–42.1) 9.7% (5.7–13.7)

I never get anyfeedback after Ireport an adverseevent.

NS NE 2.3% (0.3–4.4) 21.0% (15.5–26.5) 25.7% (19.8–31.6) 40.2% (33.6–46.8) 10.8% (6.6–14.9)E 6.0% (2.8–9.2) 18.5% (13.3–23.7) 29.6% (23.5–35.8) 35.7% (29.2–42.1) 10.2% (6.1–14.2)

I wonder about whoelse will haveaccess toinformation Idisclose.

NS NE 7.1% (3.6–10.5) 33.8% (27.4–40.2) 19.7% (14.3–25.1) 30.5% (24.3–36.7) 8.9% (5.1–12.8)E 7.4% (3.9–10.9) 34.3% (27.9–40.6) 25.9% (20.0–31.8) 24.1% (18.3–29.8) 8.3% (4.6–12.0)

As long as the staffinvolved learn fromincidents it isunnecessary todiscuss themfurther.

NS NE 0.0% (0–0) 1.9% (0.0–3.7) 9.8% (5.8–13.8) 61.7% (55.1–68.2) 26.6% (20.7–32.6)E 0.5% (0.0–1.4) 5.1% (2.1–8.0) 9.2% (5.3–13.1) 66.3% (60.0–72.7) 18.9% (13.6–24.1)

Data are presented as percentage with confidence interval.NE � group No Error; E � group Error; NS � not significant.a Wilcoxon-Mann-Whitney test.b Corrected P� values are shown. Raw P values have been corrected for effect of multiple comparisons using Ryan-Holm step-down Bonferroni correction.


medical training and practice frequently inhibits errordisclosure34 and that hiding, denying, or covering up errorsoccurs to protect oneself.31,34,35 However, in our study, only 5%(CI, 3%–7%) of anesthesiologists agreed/strongly agreed thatthey would protect their self-interests ahead of a patient’s, forexample, by hiding or denying an error, and only 10% (CI,7%–12%) agreed/strongly agreed that they would cover up anerror if they could. These results may be affected by socialdesirability bias, whereby survey respondents answer questionsas a “good person should” rather than what they actuallybelieve.36 Our results also reflect what participants think, andthis may be different than what they would actually do whenfaced with a real situation.

Blame15–17 and a “code of silence”14 inhibit error reporting.After a serious error, physicians report high levels of emo-tional distress, shame, guilt, self-reproach, self-perceptions asfailures, fear of blame and criticism, feeling isolated fromcolleagues, fear that others will find out about the error, and

concern about their professional reputation.15,37–39 These fac-tors may contribute to the code of silence, together with pastadvice from insurance companies34 and lawyers34 to notdisclose errors, as well as the influence of the perfectibil-ity model.31,32 For our participants, the statement “Doc-tors who make errors are blamed by their colleagues”was the only statement with which more anesthesiolo-gists agreed/strongly agreed (46%; CI, 42%–51%) thandisagreed/strongly disagreed (26%; CI, 22%–30%). It is avery entrenched aspect of human psychology to blameothers.40 Blame is one of the core elements of “vulnerablesystem syndrome”40 in organizations, whereby organi-zations become more liable to adverse events becauseblame inhibits thorough and far-reaching investigationof adverse events and also impedes the development ofrobust and multilayered safety systems.40 To create asafety culture, fair treatment of those who make errorsand less punishment and blame are required.11

Table 4. Magnitude and Direction of Difference Between Section 3 Responses Where There WereStatistically Significant Differences Between Group No Error and Group Errora

Statement GroupStronglyagree, % Agree, % Neutral, % Disagree, %

Stronglydisagree, %

I am worried about litigation. NE 18 (6.2) 16 (7.3)E 8.2 (0.9) 18.1 (5.4) 7.7 (0)

I don’t want to get into trouble. NE 11.6 (0) 16.5 (6.6)E 1.8 (0) 19.1 (7.6) 7.2 (0)

My colleagues may beunsupportive.

NE 0.3 (0) 2.0 (0) 13.3 (3.1)E 2.8 (0) 12.8 (2.2)

I am worried about disciplinaryaction.

NE 4.4 (0) 14.9 (4.5)E 3.7 (0.2) 9.5 (0.5) 5.8 (0)

I may be blamed unfairly forthe event.

NE 14.2 (4.1)E 0.9 (0) 5.8 (0) 5.4 (0) 2.1 (0)

I do not want the casediscussed at meetings.

NE 19.7 (8.1)E 0.4 (0) 10.5 (3.4) 2.6 (0) 6.2 (0)

Items are placed in the rows corresponding to the preferred response.NE � group No Error; E � group Error.a Expressed as difference between raw percentages. Items in parentheses are the percentage difference between the upper 95% confidence limit of the lowergroup and the lower 95% confidence limit of the higher group. Zero denotes confidence limits overlap.

Table 5. Section 2: Statistically Significant Demographic Influences on Responses of Group No Error andGroup Error

Group StatementDemographiccharacteristic

Stronglyagree Agree Neutral Disagree

Stronglydisagree

NE I am worriedaboutdisciplinaryaction.

�20 y consultanta 0.0% (0.0–0.0) 5.0% (0.0–10.7) 15.0% (5.7–24.3) 50.0% (37.0–63.0) 30.0% (18.1–41.9)10–20 yb 0.0% (0.0–0.0) 0.0% (0.0–0.0) 2.7% (0.0–8.4) 66.7% (50.5–82.8) 30.6% (14.7–46.4)�10 yc 0.0% (0.0–0.0) 3.4% (0.0–8.1) 15.3% (5.8–24.7) 52.5% (39.4–65.7) 28.8% (16.9–40.7)

Resident 1.8% (0.0–5.3) 23.2% (11.8–34.6) 8.9% (1.2–16.6) 51.8% (38.3–65.3) 14.3% (4.8–23.7)E I do not

knowwhichadverseeventsshould bereported.

�20 y consultantd 0.0% (0.0–0.0) 9.4% (1.3–17.6) 5.7% (0.0–12.1) 49.1% (35.1–63.0) 35.8% (22.5–49.2)10–20 ye 4.2% (0.0–10.0) 4.2% (0.0–10.0) 10.4% (1.5–19.4) 56.2% (41.7–70.1) 25.0% (12.3–37.7)

�10 y 0.0% (0.0–0.0) 12.8% (4.8–20.9) 8.6% (1.8–15.3) 64.3% (52.8–75.8) 14.3% (5.8–22.7)Resident 2.3% (0.0–6.9) 25.0% (11.7–38.3) 9.1% (0.3–17.9) 59.1% (44.0–74.2) 4.5% (0.0–11.0)

Data are presented as percentage with confidence interval.NE � group No Error; E � group Error.a More than 20 years as consultant versus residents, P� � 0.039.b Ten to 20 years as consultant versus residents, P� � 0.004.c Fewer than 10 years as consultant versus residents, P� � 0.04.d More than 20 years as consultant versus residents, P� � 0.0006.e Ten to 20 years as consultant versus residents, P� � 0.021.Raw P values obtained from Wilcoxon-Mann-Whitney post hoc analysis after Kruskal-Wallis testing and corrected P� values shown, corrected for multiplecomparisons using Ryan-Holm step-down Bonferroni correction.



Culture has been defined as “the way we do things aroundhere,” and can vary among and within organizations.41 Al-though most of our sample participants disagreed/stronglydisagreed or were neutral that “medicine has a culture of silencewhere errors are not talked about,” we still had 37% (CI,32%–41%) of our sample participants who agreed/stronglyagreed with this statement, suggesting that “silence” may stillinfluence our participants.

Section 2: Adverse Event With or Without ErrorAnesthesiologists in group Error were more likely to agreewith barriers concerning litigation, disciplinary action,“trouble,” blame, lack of support from colleagues, and notwanting the case discussed in meetings, than those ingroup No Error. Traditionally, physicians have been dis-couraged by medical indemnity insurers, hospital lawyers,and risk managers from disclosing errors.34 Reporting isinhibited by concern that adverse event reports disclosingerror could be discoverable material by a plaintiff’s law-yers.2,42 Opinion varies as to whether error disclosureaffects risk of litigation,43 but 58% (CI, 51%–64%) of ourgroup Error anesthesiologists perceived the risk of litiga-tion as a barrier to reporting an adverse event caused byerror, compared with 31% (CI, 25%–37%) of group NoError, suggesting that litigation remains a barrier to errorreporting. In previous survey research, 21% of a mixed

sample of physicians from medical units, surgical units,emergency departments, and intensive care units in thestate of South Australia agreed (strongly agreed/agreed) “Iam worried about litigation” is a barrier to reportingincidents.20 Victoria and South Australia have similar tort-based adversarial legal systems and the same nationalspecialist and general practitioner training programs. Ourstudy’s very specific and personalized case scenario mayhave resulted in more concern about litigation.

A sense of isolation from colleagues and fear of criticismafter making an error often have a major impact onphysicians who have made a medical error,15,39 which mayaccount for anesthesiologists in group Error being twice aslikely to agree/strongly agree than those in group No Errorwith the statement, “My colleagues may be unsupport-ive.” In previous South Australian research,20 the barrierof “My coworkers may be unsupportive” was agreed(agreed/strongly agreed) with by 14% of surveyed phy-sicians, similar to the percentage agree/strongly agree inour group No Error for “My colleagues may be unsup-portive” but less than half the percentage agree/stronglyagree for our group Error for this statement. Perceivedsupport from colleagues may differ with whether or notone has made an error.

The anesthesiologists in our sample seem to be aware ofthe importance of reporting adverse events for improved

Table 6. Section 3: Strategies to Improve ReportingStatement Strongly agree Agree Neutral Disagree Strongly disagree

Generalized deidentified feedbackabout reports received from theanesthetic community.

35.2% (30.7–39.7) 59.0% (54.4–63.7) 4.6% (2.6–6.6) 0.5% (0.0–1.1) 0.7% (0.0–1.5)

Role models, e.g., senior colleagues,departmental directors who openlyencourage reporting.

35.0% (30.4–39.5) 56.0% (51.3–60.7) 6.5% (4.1–8.8) 1.8% (0.6–3.1) 0.7% (0.0–1.5)

Legislated protection of informationyou provide from use in litigation.

45.2% (40.5–50.0) 44.6% (39.8–49.2) 7.7% (5.1–10.2) 1.6% (0.4–2.8) 0.9% (0.0–1.8)

Ability to report anonymously. 34.8% (30.3–39.3) 49.2% (44.4–53.9) 10.2% (7.3–13.1) 4.4% (2.5–6.3) 1.4% (0.3–2.5)Clear guidelines about what adverse

events and errors to report.19.7% (15.9–23.5) 63.1% (58.5–67.7) 11.6% (8.6–14.6) 5.4% (3.2–7.4) 0.2% (0.0–0.7)

Information on how confidentiality willbe maintained if you supply yourname.

25.3% (21.2–29.5) 54.2% (49.5–58.9) 12.8% (9.6–15.9) 5.6% (3.4–7.7) 2.1% (0.7–3.4)

Individualized feedback to you aboutreports you submit.

20.4% (16.6–24.2) 58.6% (53.9–63.2) 14.8% (11.5–18.2) 5.5% (3.4–7.7) 0.7% (0.0–1.4)

Paper forms for reporting provided ineach theatre.

20.6% (16.8–24.4) 52.1% (47.3–56.8) 17.3% (13.8–20.9) 9.3% (6.5–12.0) 0.7% (0.0–1.5)

More support from colleagues. 15.8% (12.3–19.2) 53.8% (49.1–58.6) 23.7% (19.6–27.7) 5.3% (3.2–7.5) 1.4% (0.3–2.5)Less blame attached to those who

report errors.16.0% (12.5–19.5) 50.8% (46.1–55.6) 19.7% (15.9–23.5) 10.9% (7.9–13.9) 2.6% (1.1–4.0)

ANZCA Continuing ProfessionalDevelopment points for reports.

12.5% (9.4–15.6) 53.7% (50.0–58.4) 18.3% (14.6–21.9) 12.0% (8.9–15.1) 3.5% (1.7–5.2)

Access to computer-based reportingsystems from home.

18.7% (15.0–22.4) 46.3% (41.6–51.0) 16.9% (13.3–20.4) 13.9% (10.6–17.2) 4.2% (2.3–6.1)

Education about the purpose ofreporting.

9.7% (6.9–12.6) 49.0% (44.2–53.7) 28.8% (24.5–33.1) 10.9% (7.9–13.8) 1.6% (0.4–2.8)

Computer-based reporting systems. 13.4% (10.2–16.7) 38.9% (34.3–43.5) 27.1% (22.6–31.0) 15.7% (12.3–19.2) 4.9% (2.8–6.9)Training on how to use computer-

based system.9.9% (7.1–12.8) 41.7% (37.0–46.3) 31.5% (27.1–35.9) 12.3% (9.2–15.4) 4.6% (2.6–6.6)

Training on how to fill in paper formsfor reporting.

9.9% (7.1–12.8) 35.3% (30.7–40.0) 33.9% (29.4–38.4) 18.3% (14.7–22.0) 2.6% (0.1–4.0)

Payment for time taken to report. 2.3% (0.9–3.7) 17.2% (13.6–20.7) 24.6% (20.5–28.7) 39.9% (35.3–44.5) 16.0% (12.5–19.5)

Data are presented as percentage with confidence interval.ANZCA � Australian and New Zealand College of Anaesthetists.


quality of care. Only 2% (CI, 0.1%–3.5%) of participants inour study agreed/strongly agreed that “Adverse eventreporting makes little contribution to quality of care,”compared with the 29% of the South Australian physicianswho agreed that “Adverse incident reporting is unlikely tolead to system changes.”20 Furthermore, in a survey ofAmerican physicians working in departments of internalmedicine and surgery in a large Midwest academic medicalcenter in the United States, the perceived barriers to errorreporting of “Not knowing the usefulness of the report”and “Thinking that reporting has little contribution forimprovement of quality of care” were among the top 6 of 17barriers,19 whereas in our study, “Adverse event reportingmakes little contribution to quality of care” was the state-ment least agreed with of our 17 statements.

Our participants were also less likely to agree with, “Idon’t know whose responsibility it is to make a report,”with only 4% (CI, 2%–6%) agreeing/strongly agreeing withthis, compared with 38% of physicians in another study.20

Similarly, only 26% (CI, 22%–30%) of our participantsagreed/strongly agreed that “The forms take too long andI just don’t have time,” compared with 54% of physicians inanother study.20

Section 3: Strategies to Improve ReportingThe importance of obtaining generalized feedback is high-lighted by the fact that “Generalized deidentified feedbackabout reports received from the anesthetic community”was the most popular strategy in our study. The need forrole models who encourage reporting was similarly popu-lar. Our participants commented very enthusiastically inour survey’s free-text section about supportive and non-judgmental department heads and senior anesthesiologistswho discuss their own errors with junior staff, and activelylead the way in reporting. Leadership that actively encour-ages and supports reporting of incidents and errors isrecognized in other safety-critical industries as essential tocreate a safety culture.44 The need for legislated protectionof adverse event and error reports from legal discoverabil-ity was also supported by participants. Successful reportingsystems should be confidential, nonpunitive, systems ori-ented (recommending changes in systems, processes, orproducts), involve expert analysis by those who under-stand clinical settings, and be timely and responsive.45

The anesthesia residents and less experienced anesthe-siologists agreed or strongly agreed more than the moreexperienced anesthesiologists with the assistive strategies

Table 7. Section 3: Statistically Significant Demographic Influences of Years Qualified, Gender, andPractice Type on Strategies to Improve Reporting

StatementDemographiccharacteristic

Stronglyagree, % Agree, % Neutral, % Disagree, %

Stronglydisagree, %

Payment for time taken toreport.

�20 y consultanta 1.8 (0.0–4.2) 8.8 (3.5–14.0) 26.3 (18.1–34.5) 37.7 (28.7–46.7) 25.4 (7.3–33.6)10–20 y consultantb 0.0 (0.0–0.0) 11.9 (4.8–19.0) 25.0 (15.5–34.5) 42.9 (32.1–53.7) 20.2 (11.5–29.0)�10 y consultant 2.3 (0.0–5.0) 18.0 (11.2–24.7) 25.8 (18.1–33.5) 39.8 (31.2–48.4) 14.1 (8.0–20.2)Resident 5.0 (0.7–9.3) 28.0 (19.0–37.0) 21.0 (12.9–29.1) 42.0 (32.2–51.8) 4.0 (0.1–7.9)

Less blame attached to thosewho report errors.

�20 y consultantc 9.7 (4.1–15.3) 39.0 (29.8–48.1) 30.1 (21.5–38.7) 16.8 (9.8–23.8) 4.4 (0.6–8.3)10–20 y consultantd 16.7 (8.5–24.8) 45.2 (34.4–56.1) 25.0 (15.5–34.4) 9.5 (3.1–15.9) 3.6 (0.0–7.6)�10 y consultant 15.5 (9.2–21.8) 58.1 (49.5–66.8) 16.3 (9.8–22.7) 7.8 (3.0–12.4) 2.3 (0.0–4.9)Resident 23.0 (14.6–13.4) 60.0 (50.2–69.8) 8.0 (2.6–13.4) 9.0 (3.3–14.7) 0.0 (0.0–0.0)

More support fromcolleagues.

�20 y consultante 11.5 (5.5–17.5) 39.8 (30.7–50.0) 39.0 (29.8–48.1) 6.2 (1.8–10.7) 3.5 (0.1–7.0)10–20 y consultantf 11.9 (4.8–19.0) 50.0 (39.1–60.9) 29.8 (19.8–39.7) 7.1 (1.2–12.8) 1.2 (0.0–3.6)�10 y consultantg 13.2 (7.3–19.1) 64.3 (56.0–72.7) 17.0 (10.5–23.6) 4.7 (1.0–8.3) 0.8 (0.0–2.3)Resident 27.0 (18.1–35.8) 59.0 (49.2–68.8) 11.0 (4.8–17.2) 3.0 (0.0–6.4) 0.0 (0.0–0.0)

Role models, e.g., seniorcolleagues, departmentaldirectors who openlyencourage reporting.

�20 y consultanth 25.4 (17.3–33.6) 58.8 (49.6–67.9) 14.0 (7.6–20.5) 1.8 (0.0–4.2) 0.0 (0.0–0.0)10–20 y consultanti 25.0 (15.5–34.5) 61.9 (51.3–72.5) 7.1 (1.5–12.8) 2.4 (0.0–5.7) 3.6 (0.0–7.6)�10 y consultantj 31.8 (23.6–39.9) 61.2 (52.7–69.8) 3.9 (0.5–7.2) 3.1 (0.1–6.1) 0.0 (0.0–0.0)Resident 58.0 (48.2–67.8) 41.0 (31.2–50.8) 1.0 (0.0–2.9) 0.0 (0.0–0.0) 0.0 (0.0–0.0)

Ability to report anonymously. Femalek 47.3 (38.7–56.0) 41.2 (32.7–49.8) 8.4 (3.6–13.2) 2.3 (0.0–4.8) 0.8 (0.0–2.3)Male 29.4 (24.2–34.6) 52.9 (47.1–58.5) 11.0 (7.4–14.6) 5.0 (2.5–7.5) 1.7 (0.2–3.1)

Role models who openlyencourage reporting.

Private practicel 23.1 (15.5–30.8) 61.2 (52.3–70.0) 11.6 (5.8–17.4) 3.3 (0.1–6.5) 0.8 (0.0–2.4)Public practicem 46.0 (39.8–52.2) 48.4 (42.2–54.6) 3.6 (0.1–5.9) 1.6 (0.0–3.1) 0.4 (0.0–1.2)Mixed private/public 11.8 (3.4–20.4) 78.0 (67.0–88.9) 8.5 (1.2–15.8) 0.0 (0.0–0.0) 1.7 (0.0–5.1)

Data are presented as percentage with confidence interval.a More than 20 years as consultant versus residents, P� � 0.0001.b Ten to 20 years versus residents, P� � 0.001.c More than 20 years versus residents, P� � 0.0001, and �20 years versus �10 years, P� � 0.001.d Ten to 20 years versus residents, P� � 0.034.e More than 20 years versus residents, P� � 0.0001, and �20 years versus �10 years, P� � 0.002.f Ten to 20 years versus residents, P� � 0.0005.g Fewer than 10 years versus residents, P� � 0.019.h More than 20 years versus residents, P� � 0.0001.i Ten to 20 years versus residents, P� � 0.0001.j Fewer than 10 years versus residents, P� � 0.0004.k Female versus male, P� � 0.036.l Private versus public practice, P� � 0.0001.m Public versus mixed private/public, P� � 0.0001.Raw P values obtained from Wilcoxon-Mann-Whitney post hoc analysis after Kruskal-Wallis testing. P� values shown have been corrected for multiple comparisonsusing Ryan-Holm step-down Bonferroni correction.



of “Less blame attached to those who report errors” and“More support from colleagues.” It is unclear whether thisis because the residents and less experienced anesthesiolo-gists perceive themselves as being blamed and unsup-ported, or whether they are more educated about the effectsof blame and lack of support on reporting, and are thusmore able to identify and name what happens in theirdepartments when they do report.

The least popular strategy was “Payment taken for timeto report,” although interestingly, our young participantswere approximately 4 times more likely to agree with thisthan our older participants. This may reflect generationaldifferences in expectations of payment for professionalactivities.

Limitations of the StudyOur sample participants were anesthesiologists and anes-thesiology residents in Victoria, Australia, and thus theresults may not be transferable to anesthesiologists in othercountries and possibly, although less likely, to other Aus-tralian states. The medicolegal context in Victoria and otherAustralian states is an adversarial, tort-based system inwhich patients can sue for medical negligence. Differentmedicolegal environments in other countries may influenceperceived reporting barriers. An advantage of our Austra-lian setting is that a recently published survey research onreporting barriers is also Australian,20 although this re-search was conducted in the state of South Australia ratherthan Victoria. However, medical practitioners in Australiaundergo their specialist or general practice training, exami-nations, and accreditation under the auspices of nationalAustralian, not state-based, organizations, which mayminimize differences between participants in differentstates.

Responder bias may also have influenced the results.For example, those who responded to our survey may bemore interested in adverse event and error reporting thanthe nonrespondents. Other potential confounding factorsinclude social desirability bias,36 which may have particu-larly affected the results for sections 1 and 2. Furthermore,the order in which statements are presented in surveys, thewording used, and the context in which they are consid-ered can also affect results.46,47 For example, the surveyitems in section 2 were answered for a specific case scenarioand patient outcome. Different cases and different patientoutcomes may elicit different perceived barriers to report-ing. Our study used previously published survey itemswhere possible, but the items had not, to our knowledge,undergone psychometric analysis. A validated measure ofhealth professionals’ attitudes to clinical adverse eventreporting has been developed using a mixed group ofphysicians and nurses.48 However, our study has a morespecific focus on emotional barriers and error reporting.

CONCLUSIONThe majority of anesthesiologists in our study did not agreethat attitudinal/emotional barriers would operate in thecontext of reporting an unspecified adverse event causedby an error, with the exception of concern about beingblamed by colleagues. When a specified anaphylaxis eventhad been caused by an error, 6 perceived barriers to

reporting the specified event differed with the presence orabsence of error. Anesthesiologists in our study stronglysupported assistive reporting strategies. Finally, thereseems to be differences between our sample and otherphysician groups for some perceived barriers to reporting,such as the contribution of adverse event reporting toquality of care, time required to complete forms, and whoseresponsibility it is to report.

DISCLOSURESName: Gaylene C. Heard, MBBS, FANZCA, MHumanFact.Contribution: This author helped design the study, conductthe study, analyze the data, and write the manuscript.Attestation: Gaylene C. Heard has seen the original study data,reviewed the analysis of the data, approved the final manu-script, and is the author responsible for archiving the studyfiles.Name: Penelope M. Sanderson, PhD, FASSA.Contribution: This author helped design the study, write themanuscript, review the data analysis, and give statistics advice.Attestation: Penelope M. Sanderson has seen the originalstudy data, reviewed the analysis of the data, and approvedthe final manuscript.Name: Rowan D. Thomas, MBBS, FANZCA, MPH.Contribution: This author helped conduct the study, analyzethe data, and review the manuscript.Attestation: Rowan D. Thomas has seen the original studydata, reviewed the analysis of the data, and approved the finalmanuscript.

ACKNOWLEDGMENTSThe authors thank Professor John Ludbrook, University ofMelbourne, for statistics review and advice. The authors alsothank Associate Professor David Story and the ANZCA TrialsGroup for permission to mail the survey to ANZCA fellowsand trainees, and the staff at ANZCA who addressed andmailed the survey packages.

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Barriers to Adverse Event and Error Reporting in AnesthesiaA2012Heard... · search on physicians’ perceived barriers to reporting is further limited because results are reported