New Study Finds Association between Human Error and Surgical Adverse Events

[J.Adderton]

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.

[NerdeNurse, ADN]

2 hours ago, Undercat said:

It it cleaner, quicker and less traumatic to have the foley done in the OR. Only takes a minute.

1

I agree. The only reason I used the foley as an example was that it was specifically mentioned as a distraction in the actual study.

[Helen M. French]

Hi, the unconsciousable issue about all the "verbiage and data" on "FAILURES" is that IT IS ALL UNDER REPORTED and full of misinformation and half truths; I am not one to argue any more about these "FAILURES". The tip of the iceberg is there, just waiting to expose the iceberg, through ALL the stories of ALL the victims or their families. ALL litigious "FAILURES are in the main hospital Risk Managers' files, while the rest are on the units, in their files. Sadly, when a "FAILURE" occurs in the operating room, the "post-op diagnosis" is always, "Complications of Surgery" and if one of the OR "FAILUREs" gets taken to the ICU quickly enough, then it is charted that the "death" occurred in ICU, or in Cardiac etc. etc etc., thus then IT is up to them to come up with a reason for their "death" The trouble is that all the media stories etc. end up as just "talk and more talk and "SILENCE", all of which just enlarge the killing field. I hope you can really research the "topic" more fully and if you ever want to share the data, I will include IT all into my "notebook/binder" for the White House. Blessings, frenchie i.e. Helen M French BSN, ADN/RN, an operating room nurse to whom ALL life is precious.