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New Study Finds Association between Human Error and Surgical Adverse Events

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by J.Adderton J.Adderton, MSN (Member) Writer Innovator Expert

J.Adderton has 20 years experience as a MSN .

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Human Performance Deficiencies in the OR

Today’s surgical settings are focused on patient safety and rich in standards, protocols and policies aimed at preventing medical errors. However, there is always a risk of potentially life-threatening human error. Researchers at Baylor College of Medicine conducted an analysis of surgical adverse events that occurred over a 6-month period. The results, published in JAMA Network Open, were eye-opening and will assist in strategy development to reduce the risk of human performance deficiencies.

New Study Finds Association between Human Error and Surgical Adverse Events

A new study published July 31, 2019, in JAMA Network Open, reveals more than half of surgical adverse events were caused by human performance deficiencies (HPDs).  Baylor College of Medicine researchers conducted the quality improvement study to analyze surgical errors that could have been prevented. 

Data Collection

Surgery residents, fellows and faculty conferenced weekly to analyze the previous week’s adverse events from general surgery, acute day care surgery, surgical oncology, cardiothoracic surgery, vascular surgery and abdominal transplantation services. Over a period of 6 months, the conference was used to review, in real time, human errors leading to the adverse events.

Researchers collected data from 3 teaching hospitals, a level 1 municipal trauma center, university hospital and a U.S. Veterans Administration hospital.  A new tool was developed and implemented that classified HPDs into five categories:

  1. Planning or problem solving
  2. Execution
  3. Rules violation
  4. Communication 
  5. Teamwork

The tool used subcategories to better understand the types of errors that were occurring.

What the Numbers Revealed

During the 6-month period, 5,300 surgeries were performed.  Adverse events occurred in 188 cases and included:

  • Death
  • Infection
  • Bleeding
  • Neurological complication
  • Hospital rehospitalization

Of the 188 adverse event cases, human performance deficiencies were identified in 106 (more than 50 percent).  Lack of attention, lack of recognition or cognitive bias were found to cause more than half of the HPDs. Over half of the events (54.8%) occurred during surgery, 8% occurred preoperatively and 26.6 postoperatively.  The adverse event incident rates fell within the following categories:

  • Execution 51.6%
  • Planning or problem solving- 29.3%   
  • Communication- 12.8%
  • Teamwork-4.8%
  • Rules violation- 3.2%

These findings were not specific to just one facility and no significant differences in events between the three hospitals or surgical service lines were identified.

Insight into National Rates

Dr. Todd Rosengart, chair and professor of the Michael E. DeBakey Department of Surgery at Baylor and the chief author provided a larger perspective of the study’s findings:

Quote

“There are approximately 17 million surgeries performed in the United States each year.  If the adverse outcome rate is about 5 percent and half those are due to human error, as seen in our cohort and reported in other studies, it would mean that about 400.000 adverse outcomes could be prevented each year.

Recommendations for Moving Forward

The study’s authors highlight the opportunity to develop simulation-based cognitive training for health care practitioners such as simulation playbacks of real-life scenarios.  They further recommend other academic medical centers and community hospitals implement regularly scheduled conference to analyze adverse events in real-time as a learning opportunity.  In the past, systems have been built to reduce the risk of human error with less focus on teaching medical staff to address their own human deficiencies. Dr. Rosengart states, “instead of adding another checklist, we want to train people to be more in touch with their vulnerability to human performance deficiency. We have to train people to listen to the voice in the back of their head”.

Are you surprised by the study’s findings?

You can read the full article here.

Suliburk, J., Buck, Q, Pirko, C., Masserweh, N., Barshes, N., Signh, H. & Rosengart, T.  (2019). Analysis of human performance deficiencies associated with surgical adverse events, Jama Network Open, 2(7)e.

Nurse with over 20 years nursing experience with a 360 nursing career- bedside, management and leadership, nursing education and currently back to the bedside. Enjoys writing about what she experiences in her own nursing practice and experience.

7 Followers; 71 Articles; 28,752 Profile Views; 298 Posts

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 I read the full article and I believe this is a very valuable study with important findings and implications.  I agree completely with the Recommendations for Moving Forward.

 

Edited by Susie2310

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subee has 45 years experience as a MSN, CRNA.

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Another study from the German Institute of the Patently Obvious. 

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Even if it seems obvious that human performance deficiencies contribute to many surgical errors (as they do to medical/ nursing errors in general), a study that demonstrates this and that facilitates study participants in reviewing/analyzing their errors in real time means that methods can be devised to reduce these types of errors in the future.   I think this is a very valuable finding, particularly as medical errors have been shown to result in large numbers of patient deaths annually.

If reviewing/analyzing medical errors/adverse events from the point of view of human errors in providing care in real time was an accepted practice in all facilities, it appears that there would be a decrease in medical errors which have the potential to cause harm to patients.

I think the researchers/study participants deserve credit for their efforts.  Recognizing one's own deficiencies is an important part of being able to see what we need to change in our own behavior to reduce our errors in care (which can and often do harm patients).  Accountability at an individual level for the care one provides is very important.  

On a negative note, I think that some practitioners may feel threatened by these findings and be reluctant to engage in a similar process of self-review.  I believe it is always more comfortable to look for the solution outside of ourselves.  I think that a number of practitioners will resist the idea that the care they provide could be deficient in any way and will prefer to ascribe all errors in care to systems errors.

Edited by Susie2310

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Undercat has 41 years experience as a BSN, MSN, CRNA and specializes in Retired.

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Call me cynical, but time-outs didn't improve anything for anybody.  An anxious patient can't be sedated before going into the OR and having a time out when they are usually just watching our lips move and agree to the wrong leg, wrong arm, etc.  We have thousands of studies of safety in the OR and yet.....arrogant surgeons are operating on the wrong side of the head.  

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Hollyhocks720 specializes in RN.

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On 8/8/2019 at 10:16 AM, subee said:

Another study from the German Institute of the Patently Obvious. 

OMG....agree...they HAVE to come up with better titles for studies so if they are valid (this one sounds pretty obvious - not requiring a study...) that they don’t give the impression of a waste of time and money.  How about “reducing adverse events causes by human error” ... ???

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Ok,so these people got a big dollar grant, looked at some surgeries, wrote an article and got it published.  Nothing new, I have been an RN since 1974 and those results were the same back then, only nobody made big bucks studying it.  Boo-boo's happen.  The more surgeries and the more complicated the procedure; Duh, the more mistakes.  Look at the good outcomes...

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After being an OR RN for decades with also 20 years of employment at University of Virginia Health System, where I worked in ALL the OR specialties and etc., my  passion has been and still is for SAFE PATIENT CARE i.e. No procedure or surgery is simple! However, at the end of the day, even though I know that there are many great health care professionals everywhere in health care arena, the "FEW" that have caused/causing  the unconsciousable carnage, which I call "FAILURES", need to be "called out", but the "SILENCE" by many also make them complicit, so thus,  leaving a trail of carnage, day in and day out.....i.e. 1,200+ per day, 36,000+ per month, and 440,000+ yearly; the "numbers" have been there since 1999, per "to Err is Human" (and later), a report which stated that 98,000 patients die yearly from "medical mistakes/errors!  Now newest  "numbers" (1,200+, 36,000+, 440,000+) are from 2014, a Congressional Senate Hearing.  NOW, here IT is 2019.  Again, I an NOT against any health care professional.  I am just trying to get out the "truths" about the "INSIDERS" who cause the "FAILURES",  of all which, ALL the "INSIDERS" in each facility KNOW about, BUT are scared to speak about due to fear of losing their jobs.  These "FAILURES" are the "third leading cause of death in the USA."  Many purport that the numbers in the US are over one million "deaths" per year!  Again, I can not imagine what the "numbers" are in 2019?  Please, review the 2014 Senator Bernie Sanders’ "Senate Hearing on Medical Mistakes" video and written reports; I ask, "What was done to really warn the public?")
https://www.sanders.senate.gov/newsroom/medical-mistakes
https://www.c-span.org/video/... Watching Health Care Mistakes and Costs @CSPAN https://www.c-span.org/video/...
https://www.hopkinsmedicine.org/…/study_suggests_medical_er…
https://www.cnbc.com/.../medical-errors-third-leading-cause-
https://www.infectioncontroltoday.com/.../diagnostic... ( How ‘Dr. Death’ Left a Trail of Horror Across Texas Hospitals, Leaving 33 Patients Maimed or Dead; A new Oxygen series, License to Kill, explores the legacy of grievously injured patients left by Dr. Christopher Duntsch .........https://people.com/.../christoph.../.....................                    The "STORIES" that victims' families share with me BREAK my heart.  I have "thousands" of "sad stories of needless deaths" from the past to the present!  The "FAILURES", in my expert Operating Room opinion, are "needless" and can be stymied and/or stopped IF the "GOOD" health care professionals would feel free to speak out with any retaliation.  Blessings, frenchie i.e. Helen M French BSN, ADN/RN, an operating room nurse to whom ALL life is precious. (SEE the PIC of my "NOTEBOOK/BINDER" on FACEBOOK,  which, I complied i.e. the 12 MAIN CAUSES of  the CARNAGE (with also the no-cost solutions) within our USA health care system. Recently, I said, "Enough is Enough", after a "daughter" was euthanized without the permission of her parents and then "PLUG" plugged,  even before they could say "GOODBYE" to her.)  I WILL GET this "binder/notebook" to the proper people. If anyone wants to assist me, "friend" me on FACEBOOK, and we will talk. There on Facebook, go to my name: Helen M French, CLICK on,  "ABOUT" and then CLICK on,  "Details About You", for a synopsis of my CV.   Thank you!    frenchie  

 

 

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NerdeNurse is a ADN and specializes in Open Heart ICU, MICU, SICU, PACU and Pre-Op.

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J. Adderton, you summed it up well.

Quote

The study’s authors highlight the opportunity to develop simulation-based cognitive training for health care practitioners such as simulation playbacks of real-life scenarios.

 

 

I enjoyed your article, so I went to the full study article.  I was disappointed in the actual study for four main reasons.

1.       The authors of the study wrote, “Our study is potentially limited in that our HPD adjudication method does not provide absolute certainty as to the primary cause of adverse events, in part because it relies on self-reporting, which in turn must occur in a just culture” and “It must also be recognized that this study was performed in an academic medical setting and involved a heterogeneous sample of surgical operations that may not be applicable to other institutions with different cultures and case mixes”.

2.       Out of the 188 cases, 6 were nonsurgical?

3.       To me, it seemed that the study was too broad. I may have missed it but I wished I could have seen the tool used for collecting the data.

4.       Did study only review doctors or were other disciplines included?  I would like to have seen a breakdown by profession/role because the two specific examples they wrote about were a radiologist and a surgeon.

I was impressed for a couple of reasons:

1.       That they were using real-time data and not just doing chart reviews.

2.       In the conclusion, they said, “These data suggest that an opportunity exists to develop simulation-based cognitive training of health care practitioners and teams to reinforce systems-based safety constructs, which alone were unable to prevent many adverse events in our study.19,37,38 As an example of such training, exercises could involve simulated playbacks of real-life scenarios taken from our situation, background, assessment, and recommendation anthology, similar to training performed in the aviation and aerospace industries”.

I found the following detailed in the study:

Adverse Events Associated with Human Performance Deficiency:

Hospital A = 58.3% (35 out of 60 events)

Hospital B = 61.1% (55 out of 90 events)

Hospital C = 42.1% (16 out of 38 events)

Service:

Acute Care or Trauma = 58.8% (50 out of 85 events)

Cardiothoracic = 33.3% (4 out of 12 events)

Surgical Critical Care = 50% (5 out of 10 events)

General, Colorectal, or Bariatric = 62.5% (5 out of 8 events)

Surgical Oncology = 56.6 % (30 out of 53 events)

Transplant = 60% (6 out of 10 events)

Vascular = 60% (6 out of 10 events)

The reason this information piqued my interest is:

1.       What is hospital C doing better than hospitals A and B?

2.       What is Cardiothoracic and Critical Care doing better than the others?

It would be interesting to see the profession/role breakdown and if there were repeat offenders.  I have worked in Pre-Op and PACU and have seen what a high-pressure process surgery is from beginning to end.  Some errors are system driven and some are physician-driven.  I think the role breakdown would give greater definition to this type of study.

Presenting site-specific, real-life scenarios on a regular basis is a great tool for education and improving compliance.  I think that, when presenting the scenarios, each profession/role needs to be present as a team. I have also seen pre-op team meetings increase the cohesiveness of the surgical team.  Both of these help team building and identifying potential problems before going into the OR suite. For instance, if there is a possibility that the patient needs to have a foley during surgery, maybe the foley should be placed before going back to the surgical suite. 

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The yearly "Deaths of the 440,000+ patients" within our  USA health care system:

The "Main Causes of the 440,000+ yearly deaths within our health care system due to "Medical Mistakes and/or Errors" are substantiated/described in my BINDER, I complied, as "FAILURES" i.e. per data, per research, per experiences of thousands of VICTIMS injured or maimed and/or per the experiences of the deceased VICTIMS' loved ones as well as myself, after decades of experiences during my operating room nursing career and beyond. The number of needless  "440,000+ deaths per year translates into 36,000+ deaths per month and into 1,200+ deaths per day!  This "carnage" has to be and can be stopped IF all the "INSIDERS" open up their "RISK MANAGEMENT" files i.e. no more "secrets" because of litigious "FAILURES". Also, all health care staffers have to be granted the freedom to speak up about the "FAILURES" in each of their own units, etc., without fear of retaliation or loss of their job. Every unit, every facility, in every community knows their own "FAILURES".  One example, i.e. money not appropriated for "SAFE"  patient staffing is money that is going into the salaries of CEOs and/or to especially, the managers, who are NOT, through their employees, "monitoring, nor enforcing" the hospitals' standards, policies, practices in order to ensure safe, caring, and ethical care to ALL of their patients. No "FAILURES" comes into existence over night. For example, the "water issue, the pipe corrosion, and the contaminates" in it,  i.e. "FAILUREs" discovered in 2014 in Flint, Michigan, came to the forefront by a "women" from FLINT, who "sent" foul smelling water to a Virginia Tech lab to obtain some answers as to what was really wrong with her water in FLINT.  OMGosh, the FLINT water had been diverted from "DETROIT" water pipes into FLINT water pipes where due to the "corrosion" of the aged pipes, their water was hazardous to drink, to cook with, to bathe, and unfit to sustain life of the citizens. Those "someones"  working with the infrastructures had to know the condition of the FLINT aged pipes for years, and yet, said nothing, until the Virginia Tech lab exposed the "truths".  Today, who knows how many in FLINT will come down with cancer or kidney failure and etc. Who will be able to prove that their "child's illness" came from the contaminated waters in FLINT?  Also, I challenge the readers to research the "Love Canal" issue in New York in 1978-2004 as well as the story of Erin Brockovich, a law clerk, who exposed the PG&E Company in California. Dear FOLKS, and especially, to "my community of nurses", we can not sit around any tables any longer and just "TALK, TALK, TALK". HOWEVER, I feel that we NEED a "national whistle blower protection law".  We all know the "FAILURES" and thus, WE need to take "them" to the media throughout the USA.  I have been a passionate "patient safety advocate" for decades, and I have the "bully scars and attorney bills" to prove IT!  Here in Nevada, where I relocated, I have tried, BUT the "SILENCE HAS BEEN DEAFENING.....and/or the comment have been, "not interested".  PLEASE, READ my other very very long "posting" on my FACEBOOK site under: Helen M French; I will marked IT with an ASTERISK. I need YOU all  to help me very soon with a "solution" for the issue of the "440,000+ yearly deaths within our health care system just due to "medical mistakes/medical errors", which I call "FAILURES".  NO MORE TALK! JUST ACTION! I will be in contact with YOU all within several weeks. My opinion, blessings, frenchie i.e. Helen M French BSN, ADN/RN, an operating room nurse to whom ALL life is precious.  Thank you.   🙂 

(PS: As an expert OR nurse, I know that the numbers and the "FAILURES" in the ORs are not being noted in most "open" data. Ironically, CMS knows, the malpractice attorneys know, my old UVA SON knows, the families of the millions of "victims" of our health care system know,  ETC. ETC.,  however, our trusting public does NOT and thus, OUR patients "go like sheep to the slaughter".  Is it not bizarre that in this day and time "nursing" still is trying to get SAFE "patient/nurse staffing ratios" passed?  We are "weak". We must not be strayed by glitter promises of magnet status, by becoming powerful, or by obtaining a "seat at the hospitals' committee tables", nor by nebulous promises that IF one is a goodie shoo shoo, "one" will get special "treatment" from one's manager or get that higher yearly raise, etc.  WE nurses have to stay focused on our patients no matter what pathway we take, once we become RNs.  Again, OUR patients are our most important "missions", i.e. the care and the protection of all of our "patients". With "robots" coming soon every where, WE need to be "working" together to make sure OUR patients are going to remain safe.  My opinions, Blessings to all, frenchie i.e. Helen M French BSN, ADN/RN, an operating room nurse to whom all life is precious.)  

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PS: In regard to the "440,000 yearly deaths in our health care system", I have enormous amounts of "stories and data', Please start here:

# 2014 Senator Bernie Sanders’ "Senate Hearing on Medical Mistakes" video and written reports; I ask, "What was done to really warn the public?")
https://www.sanders.senate.gov/newsroom/medical-mistakes
https://www.c-span.org/video/..

# Health Care Mistakes and Costs @CSPAN https://www.c-span.org/video/?458287-1/health-care-mistakes-costs )

https://people.com/crime/christopher-dunstch-dr-death-patients-killed-maimed/     (over 30+ patients maimed and/or killed) 

If anyone wants to assist me, "friend" me on FACEBOOK, and we will talk. There on Facebook, go to my name: Helen M French, CLICK on,  "ABOUT" and then CLICK on,  "Details About You", for a synopsis of my CV.   Thank you!    frenchie  🙂 

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Undercat has 41 years experience as a BSN, MSN, CRNA and specializes in Retired.

28 Posts; 131 Profile Views

6 hours ago, NerdeNurse said:

J. Adderton, you summed it up well.

 

I enjoyed your article, so I went to the full study article.  I was disappointed in the actual study for four main reasons.

1.       The authors of the study wrote, “Our study is potentially limited in that our HPD adjudication method does not provide absolute certainty as to the primary cause of adverse events, in part because it relies on self-reporting, which in turn must occur in a just culture” and “It must also be recognized that this study was performed in an academic medical setting and involved a heterogeneous sample of surgical operations that may not be applicable to other institutions with different cultures and case mixes”.

2.       Out of the 188 cases, 6 were nonsurgical?

3.       To me, it seemed that the study was too broad. I may have missed it but I wished I could have seen the tool used for collecting the data.

4.       Did study only review doctors or were other disciplines included?  I would like to have seen a breakdown by profession/role because the two specific examples they wrote about were a radiologist and a surgeon.

I was impressed for a couple of reasons:

1.       That they were using real-time data and not just doing chart reviews.

2.       In the conclusion, they said, “These data suggest that an opportunity exists to develop simulation-based cognitive training of health care practitioners and teams to reinforce systems-based safety constructs, which alone were unable to prevent many adverse events in our study.19,37,38 As an example of such training, exercises could involve simulated playbacks of real-life scenarios taken from our situation, background, assessment, and recommendation anthology, similar to training performed in the aviation and aerospace industries”.

I found the following detailed in the study:

Adverse Events Associated with Human Performance Deficiency:

Hospital A = 58.3% (35 out of 60 events)

Hospital B = 61.1% (55 out of 90 events)

Hospital C = 42.1% (16 out of 38 events)

Service:

Acute Care or Trauma = 58.8% (50 out of 85 events)

Cardiothoracic = 33.3% (4 out of 12 events)

Surgical Critical Care = 50% (5 out of 10 events)

General, Colorectal, or Bariatric = 62.5% (5 out of 8 events)

Surgical Oncology = 56.6 % (30 out of 53 events)

Transplant = 60% (6 out of 10 events)

Vascular = 60% (6 out of 10 events)

The reason this information piqued my interest is:

1.       What is hospital C doing better than hospitals A and B?

2.       What is Cardiothoracic and Critical Care doing better than the others?

It would be interesting to see the profession/role breakdown and if there were repeat offenders.  I have worked in Pre-Op and PACU and have seen what a high-pressure process surgery is from beginning to end.  Some errors are system driven and some are physician-driven.  I think the role breakdown would give greater definition to this type of study.

Presenting site-specific, real-life scenarios on a regular basis is a great tool for education and improving compliance.  I think that, when presenting the scenarios, each profession/role needs to be present as a team. I have also seen pre-op team meetings increase the cohesiveness of the surgical team.  Both of these help team building and identifying potential problems before going into the OR suite. For instance, if there is a possibility that the patient needs to have a foley during surgery, maybe the foley should be placed before going back to the surgical suite. 

It it cleaner, quicker and less traumatic to have the foley done in the OR.  Only takes a minute.  And you are right about having a consistent team in the room.  It's boring for anesthesia but good for the patient:)

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