Pediatric Anesthesiology Fellows’ Perception of

Quality of Attending Supervision and Medical Errors

Hubert A. Benzon, MD, MPH,* John Hajduk, BS,* Gildasio De Oliveira Jr, MD, MSCI, MBA,†
Santhanam Suresh, MD,* Sarah L. Nizamuddin, MD,‡ Robert McCarthy, PharmD,† and
Narasimhan Jagannathan, MD*

BACKGROUND: Appropriate supervision has been shown to reduce medical errors in anesthe-
siology residents and other trainees across various specialties. Nonetheless, supervision of
pediatric anesthesiology fellows has yet to be evaluated. The main objective of this survey inves-
tigation was to evaluate supervision of pediatric anesthesiology fellows in the United States. We
hypothesized that there was an indirect association between perceived quality of faculty supervi-
sion of pediatric anesthesiology fellow trainees and the frequency of medical errors reported.
METHODS: A survey of pediatric fellows from 53 pediatric anesthesiology fellowship programs
in the United States was performed. The primary outcome was the frequency of self-reported
errors by fellows, and the primary independent variable was supervision scores. Questions also
assessed barriers for effective faculty supervision.
RESULTS: One hundred seventy-six pediatric anesthesiology fellows were invited to participate,
and 104 (59%) responded to the survey. Nine of 103 (9%, 95% confidence interval [CI], 4%–16%)
respondents reported performing procedures, on >1 occasion, for which they were not properly
trained for. Thirteen of 101 (13%, 95% CI, 7%–21%) reported making >1 mistake with negative
consequence to patients, and 23 of 104 (22%, 95% CI, 15%–31%) reported >1 medication error
in the last year. There were no differences in median (interquartile range) supervision scores
between fellows who reported >1 medication error compared to those reporting ≤1 errors (3.4
[3.0–3.7] vs 3.4 [3.1–3.7]; median difference, 0; 99% CI, −0.3 to 0.3; P = .96). Similarly, there
were no differences in those who reported >1 mistake with negative patient consequences,
3.3 (3.0–3.7), compared with those who did not report mistakes with negative patient conse-
quences (3.4 [3.3–3.7]; median difference, 0.1; 99% CI, −0.2 to 0.6; P = .35).
CONCLUSIONS: We detected a high rate of self-reported medication errors in pediatric anes-
thesiology fellows in the United States. Interestingly, fellows’ perception of quality of faculty
supervision was not associated with the frequency of reported errors. The current results with
a narrow CI suggest the need to evaluate other potential factors that can be associated with
the high frequency of reported errors by pediatric fellows (eg, fatigue, burnout). The identifica-
tion of factors that lead to medical errors by pediatric anesthesiology fellows should be a main
research priority to improve both trainee education and best practices of pediatric anesthesia. 
(Anesth Analg 2017;XXX:00–00)

C
linical supervision of anesthesiology trainees plays
a major role in patient care and medical education.
Trainees actively learn from attending physicians
who closely supervise and provide consistent education and
constructive feedback. Inadequate supervision may have
negative consequences to trainees and to patient care.1–3
Medical errors are the third leading cause of all deaths and
are commonly reported in the anesthesiology specialty.4–6
It has recently been demonstrated that there is an associa-
tion between perception of resident trainee supervision in
From the *Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago,
Illinois; †Department of Anesthesiology, Northwestern University, Chicago,
Illinois; and ‡University of Chicago Medical Center, University of Chicago,
Chicago, Illinois.
Accepted for publication July 27, 2017.
Funding: This study was funded by the Department of Pediatric
Anesthesiology, Ann & Robert H. Lurie Children’s Hospital of Chicago,
Northwestern University, Chicago, Illinois.
The authors declare no conflicts of interest.
Reprints will not be available from the authors.
Address correspondence to Hubert A. Benzon, MD, MPH, Department of
Pediatric Anesthesiology, Ann & Robert H. Lurie Children’s Hospital of Chi-
cago, 225 E Chicago Ave, PO Box 19, Chicago, IL 60611. Address e-mail to
hbenzon@luriechildrens.org.
Copyright © 2017 International Anesthesia Research Society
DOI: 10.1213/ANE.0000000000002445
anesthesiology and medical errors leading to negative conse-
quences to patients during general anesthesiology residency.7
Pediatric anesthesiology fellows are more likely to be
covering higher acuity rooms that can include a more chal-
lenging patient population such as high-risk neonates,
patients with significant congenital cardiac lesions, or syn-
dromic patients with more challenging airways.8–10 While
practice patterns vary across institutions, these operating
rooms likely require closer supervision from an attending
physician.11 Nonetheless, quality of supervision for pediat-
ric anesthesiology fellows has yet to be evaluated. One may
argue that supervision of anesthesiology fellows may signif-
icantly differ from supervision of anesthesiology residents.
The primary objective of this survey investigation was
to evaluate supervision of pediatric anesthesiology fellows
in the United States and medical errors reported by fellows.
We hypothesized that there was an indirect association
between perceived quality of faculty supervision of pedi-
atric anesthesiology fellow trainees and the frequency of
medical errors reported by the fellows.
METHODS
The study was approved by the institutional review board
of Ann & Robert H. Lurie Children’s Hospital of Chicago.

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 Pediatric Fellow Supervision and Medical Errors
A mailing list for the 56 pediatric anesthesiology fellow-
ship programs in the United States was obtained from the
Accreditation Council for Graduate Medical Education, and
contact information was compiled from the Accreditation
Council for Graduate Medical Education website. Of the 56
listed programs, 53 indicated they had at least 1 fellow. An
e-mail list of current pediatric anesthesiology fellows was
obtained from the respective program coordinators and/
or fellowship directors, and a database (PostgreSQL ver-
sion 9.4.1, PostgreSQL Global Development Group) was
constructed. We followed similar methods previously used
to evaluate supervision of general anesthesiology trainees.7
The survey was created using Survey Monkey software
(SurveyMonkey Inc, Portland, OR). To assure confidential-
ity of the participants, the survey was set up to delink the
responses to the respondent’s e-mail address but retained the
Internet protocol address of the respondents. The software
uses an internal tracking system to allow only 1 response per
survey invitation and generates a list of nonresponders. The
participants who did not respond to the electronic question-
naire received 3 subsequent requests to complete the survey.
The questionnaire was divided into 4 parts and included
21 questions. Multiple-choice questions were used. Likert
scales were used to quantify respondents’ level of agree-
ment with a statement. The first 5 questions were designed
to capture characteristics of the respondents, including
age, gender, number of fellows in their class, and number
of hours worked per week. The second part of the survey
included all 9 questions from the de Oliveira Filho et al12
instrument specifically developed to examine anesthesiol-
ogy residents’ perception of quality of faculty supervision.
Each question represents a dimension of supervision. The
instrument uses a 4-point Likert scale (never = 1, rarely = 2,
frequently = 3, and always = 4). The supervision score was
calculated as the average of the individual responses to the
9 questions. The instrument has been demonstrated to have
very good internal consistency of results (Cronbach α coef-
ficient = .93; G and φ coefficients = .93).12
The third part of the survey evaluated frequency of self-
reported errors using 3 questions developed by previous
investigators and used in other medical specialties but with
applicable relevance to anesthesiology.13,14 Frequency was
evaluated using a 5-point Likert scale (5 = often, 4 = mul-
tiple times, 3 = a couple of times, 2 = once, and 1 = never).
The 3 questions pertained to the following statements: “I
perform procedures for which I am not properly trained,”
“I have made mistakes that have negative consequences
for the patient,” and “I have made medication errors (dose
or incorrect drug) in the last year.” The fourth part of the
survey represented the trainee’s level of agreement to
causes that contribute to poor supervision from anesthesia
attendings using a 5-point Likert scale (5 = strongly agree,
4 = agree, 3 = neither agree nor disagree, 2 = disagree, and
1 = strongly disagree). Factors that contributed as a barrier
to adequate supervision were assessed (lack of interest for
teaching, lack of emphasis on supervision by departmental
leadership, excessive supervisor clinical work, and lack of
capability of the attending to teach as factors contributing
to poor supervision).
The primary outcome was the frequency of self-reported
errors by the pediatric fellows. Confidence intervals (CIs)
2   
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for the rate of reported errors were calculated using the
Pearson-Klopper method. Fellow-reported supervision
scores were the independent variables of interest. The pri-
mary comparison of interest was the difference in supervi-
sion scores in fellows who reported >1 errors (performing
a procedure for which they were not properly trained, mis-
takes with negative consequences to the patient, or medica-
tion errors) with those who reported ≤1 errors in the last
year. The independent variables were assessed for normal-
ity using the Shapiro-Wilk test and did not meet the crite-
ria for a normal distribution and were compared between
reported-error frequency groups using the Mann-Whitney
U test. To correct for multiple comparisons of supervision
scores, a P <.01 was required to reject the null hypothesis.
The median difference and 99% CI for the difference were
calculated using a 10,000-sample bootstrap.
Secondary outcomes were the associations of supervision
scores with self-reported errors, fellow rating of perceived
barriers to effective supervision and responder, and program
characteristics assessed by examining nonparametric corre-
lations using the Spearman’s Rho (ρ) coefficient. Differences
in supervision scores among group characteristics of the
respondents were evaluated using the Kruskal-Wallis H test
or the Mann-Whitney U test. A P value <.05 was considered
significant for secondary outcomes. Binomial and ordinal
data are presented as count (percent of total), continuous
data as median (interquartile range [IQR]). Statistical analy-
sis was performed using Stata version 14 (College Station,
TX), RStudio version 1.0.143 (Integrated Development for
R. RStudio, Inc, Boston, MA; URL: http://www.rstudio.
com/), and R version 3.4.0, release date 4/21/2017 (The R
Foundation for Statistical Computing, Vienna, Austria).
A convenience sample of all pediatric anesthesiology fel-
lows in the United States was surveyed. Based on the finite
population size of 174 and a response rate of 59%, the mar-
gin of error for the survey was 6% at the 95% confidence
level. A post hoc power analysis was performed for the pri-
mary comparison of interest, the difference in supervision
scores between the null hypothesis of 0 and the actual dif-
ference of 0.5 between fellows who reported >1 error using
the Mann-Whitney U test at an α of .1 and standard devia-
tion of 0.4. Based on the response rate of subjects reporting
performing a procedure for which they were not properly
trained, mistakes with negative consequences to the patient,
and medication errors, the power for detecting a difference
in supervision scores was 0.74, 0.92, and 0.99 for each of
the questions, respectively. Power analysis was performed
using PASS 14 (NCSS, LLC, Kaysville, UT).
RESULTS
Pediatric anesthesiology fellows from 37 of the 53 responded
to the survey between April and mid-June of 2016, with
the median (IQR) number of fellows per institution being
7 (4–9). One hundred seventy-six pediatric anesthesiology
fellows were invited to participate and 104 responded to
the survey, resulting in a 59% response rate. Respondents
answered 2171 of the 2184 data elements (99.4%). Questions
with missing responses were excluded from analysis.
Among respondents, 47 (45%; 95% CI, 35%–55%) were men,
76 (73%; 95% CI, 63%–81%) were younger than 35 years,
and 102 (98%; 95% CI, 93%–99%) worked ≤70 hours per
ANESTHESIA & ANALGESIA
        

week (Table 1). There was no difference in the program size
of respondents, median (IQR) of 7 (3–9), compared to the
program size of nonrespondents 7 (4–9; P = .47), suggest-
ing the absence of response bias (Figure). There was also
no difference in the size of programs between respondents
and nonrespondents with a similar response rate between
regions: Northeast = 37%, Midwest = 56%, West = 46%, and
South = 42%.
The median (IQR) of supervision scores for the sam-
ple was 3.4 (3.0–3.7) (between frequent and always).
Examination of univariate analysis did not demonstrate
any association between supervision scores and program or
respondent characteristics (Table 1).
Primary Outcome
Nine of 103 (9%; 95% CI, 4%–15%) of the respondents
reported performing procedures for which they were not
properly trained for on >1 occasion, and 13 of 101 (13%;
95% CI, 7%–21%) reported >1 mistake with negative conse-
quences to patients. Twenty-three (22%; 95% CI, 15%–32%)
reported >1 medication error in the last year. There were no
differences in median supervision scores between fellows
who reported >1 error (performing a procedure for which
they were not properly trained, mistakes with negative con-
sequences to the patient, or medication errors) with those
who reported ≤1 errors in the last year (Table 2).
Secondary Outcomes
Supervision scores were not correlated with the Likert
response for the questions of performing procedures for
which trainees were not adequately trained (ρ = .02; 95% CI,
−0.19 to 0.25; P = .82), negative mistakes with consequences
to patients (ρ = .03; 95% CI, −0.17 to 0.24; P = .73), and medi-
cation errors within the last year (ρ = .00; 95% CI, −0.19 to
0.19; P = .99).
The most frequently cited (Likert 4 or 5) barriers to fel-
low supervision were a lack of interest in teaching by the
faculty, 26 of 104 (25%; 95% CI, 17%–34%) respondents,
and lack of ability of the anesthesia attending to teach, 20
of 104 (19%; 95% CI, 12%–18%) respondents. Supervision
scores were negatively correlated with the Likert response
to the questions regarding faculty barriers for supervision
(Table 3).
DISCUSSION
The most important finding of the current study was the
lack of association between the perceived supervision by
pediatric anesthesiology fellows and reported medical
errors. Furthermore, there was no association between the
perceived supervision by pediatric anesthesiology fellows
and reported mistakes with significant negative conse-
quences to patient care. This is in contrast to the findings
observed in anesthesiology residents where a significant
association occurred between lower perceived supervision
and greater incidence of medical errors with negative con-
sequences to patients.7 The data in the current study suggest
that perceived supervision reported by pediatric fellows is
likely independent of the frequency of reported error occur-
rences when compared with the association observed in
resident physicians.
There are several possible explanations that may have
contributed to the results of the current study. First, pedi-
atric anesthesiology fellows are more likely to cover higher
acuity patients undergoing more complex surgical and
medical procedures.15,16 Second, due to anatomical and
physiological differences in children and adults, it is likely
that the general pediatric population undergoing surgery
and anesthesia are at high risk for the development of rapid
complications (eg, laryngospasm, oxygen desaturations)
when compared with adults and thus may require greater
active participation by the supervising attending with the
fellow trainee.17,18 Finally, pediatric cases are more likely
to have 1-on-1 coverage (anesthesia attending to anesthe-
sia fellow trainee) versus 2 sites concurrently supervised
by the same attending in adult anesthesia practice in the
United States. Given that staffing models in the United
States are complex and dependent on a number of variable
factors (number of attendings and trainees, surgical proce-
dure, acuity of patient’s medical problems, etc), our results
should not be used to alter current staffing models. Since

Table 1.   Characteristics of Survey Respondents and Correlation With Supervision Scores
Number of Respondents (n = 104) Supervision Scores P Correlation With Supervision Score, ρ (95% CI)
Age (y) (−0.22 to 0.22)
 25–29 2 (2) 3.7 (3.5–3.7)
 30–34 74 (71) 3.4 (3.0–3.7)
 35–40 20 (19) 3.4 (2.9–3.7) .27
 >40 8 (8) 3.5 (3.1–3.9)
Gender 0.01 (−0.18 to 0.20)
 Male 47 (45) 3.4 (3.0–3.7) .91
 Female 57 (55) 3.4 (3.0–3.7)
Fellow class size −0.14 (−0.31 to 0.06)
 <4 23 (22) 3.6 (3.2–3.8)
 4–7 34 (32) 3.3 (3.0–2.6) .14
 8–9 23 (22) 3.4 (3.1–3.9)
 >9 24 (23) 3.3 (3.0–3.7)
Weekly hours −0.02 (−0.19 to 0.16)
 <50 16 (15) 3.4 (3.1–3.6)
 51–60 67 (64) 3.3 (3.0–3.7) .74
 61–70 19 (18) 3.3 (3.0–3.7)
 >70 2 (3) 3.6 (3.5–3.6)
Data presented as n (%) or median interquartile range.
Abbreviation: CI, confidence interval.

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 Pediatric Fellow Supervision and Medical Errors
Figure . Scatter plot of program size versus response rate.
Table 2.   Association of Supervision Scores With Reported Errors
Perform a procedure for which they are not properly trained
Made a mistake with negative consequences to the patient
Made a medication error
Data presented as median interquartile range or median difference (99% CI of the difference).
Abbreviation: CI, confidence interval.
Table 3.   Correlations Between Supervision Scores
and Faculty Barriers for Supervision
Correlation With
Supervision Scores,
ρ (95% CI)
Lack of interest of teaching by −0.33 (−0.51 to −0.13)
attending
Lack of emphasis on supervision −0.29 (−0.47 to −0.10)
by department leadership
Lack of time due to excessive −0.21 (−0.39 to −0.03)
clinical work
Lack of anesthesia attending’s −0.29 (−0.46 to −0.07)
capability to teach
Abbreviation: CI, confidence interval.
we did not find an association between errors and super-
vision, future studies regarding staffing models of fellows
may help determine the optimal staffing models of pediatric
fellows in the United States.
Another important finding of the current investigation
was the percentage of fellow respondents stating they were
performing procedures for which they were not properly
trained. This reported percentage (9%) is greater than what
has been reported in anesthesiology residents (7.5%).7 It is
possible that fellow trainees have been given more indepen-
dence to perform invasive procedures or that the attending
anesthesiologist was unavailable. Additionally, 13% of the
fellow trainees also had experienced >1 medical error with
negative consequences during their fellowship, compared
to 3% of the residents. Given the fragile patient population
and the reduced margin of safety in children, it is conceiv-
able that mistakes occurring at pediatric centers could lead
to more severe consequences compared to adults.
Few studies have addressed the role of supervision in
anesthesiology training in general. Schmidt et al19 observed
that close supervision of anesthesiology residents by
attending anesthesiologists was associated with a reduction
4   
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Reported Frequency
≤1 Time >1 Time Difference (99% CI of Difference) P
3.4 (3.0–3.7) 3.1 (2.9–3.8) −0.3 (−0.6 to 0.6) .83
3.3 (3.0–3.7) 3.4 (3.3–3.7) 0.1 (−0.2 to 0.6) .35
3.4 (3.0–3.7) 3.4 (3.1–3.7) 0 (−0.3 to 0.3) .96
in complications during emergency airway management
when performed by trainees. Survey tools have been used
and validated across different specialties in anesthesiology,
but none have specifically focused on pediatric fellows.20,21
P To our knowledge, this is the first study evaluating the
.001 relationship between attending supervision and anesthesia
training at the fellowship level in the field anesthesiology.
.003
Future studies should evaluate the importance and qual-
.04 ity of supervision of anesthesiology trainees, particularly
toward the evaluation of different fellowships (eg, critical
.003 care, pain medicine).
The current study should only be interpreted within the
context of its limitations. The responses were subjective
and reflected the perception of supervision by anesthesi-
ology fellows. The perception of quantity and quality of
supervision is subject to opinion and variable among fel-
low trainees, which may have influenced the results. This
study only evaluated the perception of supervision and not
actual supervision (1-to-1 coverage versus 2-to-1 coverage,
the amount of time the attending anesthesiologist is actually
present in the room with the trainee, if the attending was
present during medication administration, etc). We only
examined pediatric anesthesiology fellows, and therefore,
we cannot generalize our findings to different anesthesiol-
ogy fellowships. Finally, it is possible that an examination of
advance pediatric anesthesiology training in other countries
may result in different findings.
We detected a higher rate of self-reported errors in pedi-
atric anesthesiology fellows in the United States than previ-
ously reported in anesthesiology residents. This difference
may reflect the perception of supervision between the 2
populations. Interestingly, fellows’ perception of quality of
faculty supervision was not associated with the frequency
of reported errors. Nevertheless, the inverse associations
of supervisions scores with perceived barriers to faculty
supervision were similar among resident and pediatric
ANESTHESIA & ANALGESIA

fellow respondents. The current results suggest the need to
evaluate other potential factors that can be associated with
the high frequency of reported errors by pediatric fellows
(eg, fatigue, burnout). The identification of root-cause fac-
tors that lead to medical errors by pediatric fellows should
be a main research priority to improve both trainee educa-
tion and best practices of pediatric anesthesia. E
DISCLOSURES
Name: Hubert A. Benzon, MD, MPH.
Contribution: This author helped design and conduct the study,
and prepare the manuscript.
Name: John Hajduk, BS.
Contribution: This author helped design and conduct the study,
and prepare the manuscript.
Name: Gildasio De Oliveira Jr, MD, MSCI, MBA.
Contribution: This author helped design and conduct the study,
and prepare the manuscript.
Name: Santhanam Suresh, MD.
Contribution: This author helped design and conduct the study,
and prepare the manuscript.
Name: Sarah L. Nizamuddin, MD.
Contribution: This author helped design the study and prepare the
manuscript.
Name: Robert McCarthy, PharmD.
Contribution: This author helped contribute the statistical analysis
and revise the manuscript.
Name: Narasimhan Jagannathan, MD.
Contribution: This author helped design and conduct the study,
and prepare the manuscript.
This manuscript was handled by: Edward C. Nemergut, MD.
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