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A systems approach to surgical safety

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Conclusion

The documented and “accepted” incident rates in surgery are unacceptably high. Incident rates of 1–5% are generally accepted as a normal part of practice. Current morbidity and mortality reporting, while important, does not sufficiently examine or expose the active and latent errors that lead to adverse outcomes. Further. there is no process in place for systematically learning from surgical incident data so that appropriate changes can be incorporated in practice. Other high-risk industries have shown that process improvements, as well as the promotion of a culture of safety, can have a significant impact on an industry’s safety record. The establishment of surgical protocols and checklists has the potential to improve the standards of training and practice, as well as enhancing operating room communications. Data collection and analysis can identify latent errors that could be addressed through better training, device design, or surgical methods. Computerbased training could be instituted to allow surgeons to practice the perceptual, decision-making, and problemsolving skills that are a major part of surgery. These kinds of activities have been incorporated successfully into other industries and should also be applied to the practice of surgery.

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References

  1. Adamsen S, Hansen OH, Funch-Jensen P, Schulze S, Stage JG, Wara P (1997) Bile duct injury during laparoscopic cholecystectomy: a prospective nationwide series. J Am Coll Surg 184: 571–578

    PubMed  CAS  Google Scholar 

  2. American College of Surgeons Health Policy and Advocacy Department. http://www.facs.org/dept/hpa/testimony/hpatest.html

  3. American College of Surgeons National Trauma Registry System. http://www.facs.org/about_college/acsdept/trauma_dept/national_tracs/tracmenu.html

  4. American College of Surgeons Oncology Group. http://www.acosog.org/

  5. Andrews LB, Stocking C, Krizek T, Gottlieb L, Krizek C, Thomas V, Siegler M (1997) An alternative strategy for studying adverse events in medical care. Lancet 349: 309–313

    Article  PubMed  CAS  Google Scholar 

  6. Aston G (2000) Virginia high court favors peer review privacy. Am Med News 43: 5–6

    Google Scholar 

  7. Behrns K, Tsiotos G, Desouza N, Krishna M, Ludwig J, Nagorney D (1998) Hepatic steatosis as a potential risk factor for major hepatic resection. J Gastrointest Surg 2: 292–298

    Article  PubMed  CAS  Google Scholar 

  8. Senders JW (1994) Medical devices, medical errors and medical accidents. In: Bogner MS, Human error in medicine. Lawrence Erlbaum Associates. Hillsdale, NJ, USA. pp 159–177

    Google Scholar 

  9. Bogner S (2000) Quest for why: the systems approach to medical error institute for the study of medical error. Personal communication

  10. Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG, Newhouse JP, Weiler PC, Hiatt HH (1991) Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I. N Engl J Med 324: 370–376

    PubMed  CAS  Google Scholar 

  11. Chekan EG, Hayward TZ, Brody FJ, Purcell GP, Hayward K, Pappas TN, Eubanks WS (1998) Computers in surgical residencies. Curr Surg 55: 391–396

    Google Scholar 

  12. Cook R, Woods D, Miller C (1998) A tale of two stories: contrasting views of patient safety. Report from a workshop on Assembling the Scientific Basis for Progress on Patient Safety. Chicago, IL: National Health Care Council of the National Patient Safety Foundation at the AMA. pp. 1–74

    Google Scholar 

  13. Cook RI, Woods DD (1991) Same scene, different views: human performance in anesthesia. Human error in anesthesia. Ohio State University, USA

    Google Scholar 

  14. Cook RI, Woods DD, McDonald JS (1991) Human performance in anesthesia: a corpus of cases. Ohio State University, USA

    Google Scholar 

  15. Cooper JB, Gaba DM (1989) A strategy for preventing anesthesia accidents. Int Anesthesiol Clin 27: 148–152

    Article  PubMed  CAS  Google Scholar 

  16. Cooper JB, Newbower R (1975) The anesthesia machine: an accident waiting to happen. In: Pickett M, Triggs TJ (eds) Human factors in healthcare. DC Health & Co, Lexington, MA, USA, pp 345–358

    Google Scholar 

  17. Cooper JB, Newbower RS, Long CD, McPeek B (1978) Preventable anesthesia mishaps: a study of human factors. Anesthesiology 49: 399–406

    PubMed  CAS  Google Scholar 

  18. Degani A, Wiener E (1994) On the design of flight deck procedures. Moffett Field, CA, USA, NASA Ames Research Center Contractor Report. pp 1–73

  19. Dinges D, Pack F, Williams K, Gillen K, Powell J, Ott G (1997) Cumulative sleepiness, mood disturbance, and psychomotor vigilance performance decrements during a week of sleep restricted to 4–5 hours per night. Sleep 20: 267–277

    PubMed  CAS  Google Scholar 

  20. Dinges DF (1995) Performance effects of fatigue. Fatigue Symposium Proceedings. National Transportation Safety Board, Washington (DC)

    Google Scholar 

  21. Dominguez C (1998) Expertise in laparoscopic surgery: anticipation and affordances. Naturalistic Decision Making 4. Warrenton (VA)

  22. Dominguez C (1998) Expertise in laparoscopic surgery: anticipation and affordances. In: Proceedings of Naturalistic Decision Making 4. Warrenton, VA, USA

  23. Dubois P, Rouland JF, Meseure P, Karpf S, Chaillou C (1995) Simulator for laser photocoagulation in ophthalmology. IEEE Trans Biomed Eng 42: 688–693

    Article  PubMed  CAS  Google Scholar 

  24. Eichhorn J (1989) Prevention of intraoperative anesthesia accidents and related severe injury through safety monitoring. Anesthesiology 70: 572–577

    Article  PubMed  CAS  Google Scholar 

  25. Flanagan JC (1954) The critical incident technique. Psychol Bull 59: 327–358

    Article  Google Scholar 

  26. Gaba DM (1989) Human error in anesthetic mishaps. Int Anesthesiol Clin 27: 137–147

    Article  PubMed  CAS  Google Scholar 

  27. Gaba DM, Maxwell M, DeAnda A (1987) Anesthetic mishaps: breaking the chain of accident evolution. Anesthesiology 6: 670–676

    Google Scholar 

  28. Gawande AA, Thomas EJ, Zinner MJ, Brennan TA (1999) The incidence and nature of surgical adverse events in Colorado and Utah in 1992. Surgery 126: 66–75

    Article  PubMed  CAS  Google Scholar 

  29. Good ML, Gravenstein JS (1989) Anesthesia simulators and training devices. Int Anesthesiol Clin 27: 161–168

    Article  PubMed  CAS  Google Scholar 

  30. Herlitz J, Brandrup G, Haglid M, Karlson B, Albertsson P, Lurje L, Westberg S, Karlsson T (1997) Death, mode of death, morbidity, and rehospitalization after coronary artery bypass grafting in relation to occurrence of and time since a previous myocardial infarction. Thorac Cardiovasc Surg 45: 109–113

    Article  PubMed  CAS  Google Scholar 

  31. Howard SK, Gaba DM, Fish KJ, Yang G, Sarnquist FH (1992) Anesthesia crisis resource management training: teaching anesthesiologists to handle critical incidents. Aviat Space Environ Med 63: 763–770

    PubMed  CAS  Google Scholar 

  32. Joice P, Hanna GB, Cuschieri A (1998) Errors enacted during endoscopic surgery—a human reliability analysis. Appl Ergon 29: 409–414

    Article  PubMed  CAS  Google Scholar 

  33. Katz P (1999) The scalpel’s edge: the culture of surgeons. Allwyn & Bacon. Boston, MA, USA

    Google Scholar 

  34. Leape LL (2000) Institute of medicine: medical error figures are not exaggerated. J Am Med Assoc 284: 95–97

    Article  CAS  Google Scholar 

  35. Krizek T (2000) Surgical error: reflections on adverse events. Bull Am Coll Surg 85: 18–22

    PubMed  CAS  Google Scholar 

  36. Kurz A, Sessler D, Lenhardt R (1996) Perioperative normthermia to reduce the incidence, of surgical wound infection and shorten hospitalization: study of wound infection and temperature group. New Engl J Med 334: 1209–1215

    Article  PubMed  CAS  Google Scholar 

  37. Leape L (1994) The preventability of medical injury. In: Bogner MS (ed) Human error in medicine. Lawrence Erlbaum, Hillsdale, NJ, USA. pp 13–25

    Google Scholar 

  38. Leape LL (2000) Institute of Medicine medical error figures are not exaggerated [comment]. JAMA 284: 95–97

    Article  PubMed  CAS  Google Scholar 

  39. Laird N, Lawthers AG, Localio AR, Barnes BA, Hebert L, Newhouse JP, Weiler PC, Hiatt H (1991) The nature of adverse events in hospitalized patients: results of the Harvard Medical Practice Study II. N Engl J Med 324: 377–384

    Article  PubMed  Google Scholar 

  40. Lunn J, Devlin B (1988) Lessons from the confidential enquiry into perioperative deaths in three NHS regions. Lancet 212: 1384–1386

    Google Scholar 

  41. McDonald CJ, Weiner M, Hui SL (2000) Deaths due to medical errors are exaggerated in Institute of Medicine report [comment]. JAMA 28: 93–96

    Article  Google Scholar 

  42. Mackenzie C, Jefferies N, Hunter W, Bernard W, Xiao Y, Group TL, Horst R (1996) Comparison of self-reporting of deficiences in airway management with video analyses of actual performance. Human Factors 38: 623–635

    Article  PubMed  CAS  Google Scholar 

  43. Murphy S (2000) Deaths: final data for 1998. http://www.cdc.gov/ nchs/data/nvs48_11.pdf

  44. National Transporation Safety Board. (2000) Accidents, fatalities, and rates, 1982 through 1999, for US air carriers operating under 14 CFR 121, scheduled and nonscheduled service (airlines) www.ntsb.gov/aviation/table5.htm

  45. Pate-Cornell ME, Lakats LM, Murphy DM, Gaba DM (1997) Anesthesia patient risk: a quantitative approach to organizational factors and risk management options. Risk Anal 17: 511–523

    Article  PubMed  CAS  Google Scholar 

  46. Phillips O, Capizzi L (1974) Anesthesia mortality, Clin Anesth 10: 220–244

    PubMed  CAS  Google Scholar 

  47. Reason J (1995) Understanding adverse events: human factors. Qual Health Care 4: 80–89

    Article  PubMed  CAS  Google Scholar 

  48. Reason JT (1990) Human error. Cambridge University Press, New York, p 302

    Google Scholar 

  49. Stark E, Oestreich K, Wendl K, Rumstadt B, Hagmuller E (1999) Nerve irritation after laparoscopic hernia repair. Surg Endosc 13: 878–881

    Article  PubMed  CAS  Google Scholar 

  50. Tendick F, Downes M, Cavusoglu MC, Gantert W, Way LW (1998) Development of virtual environments for training skills and reducing errors in laparoscopic surgery. Proceedings of the SPIE (International Society for Optical Engineering). International on Biological Optics (BIOS 98) San Jose, CA, USA. pp 36–44

  51. Thomas EJ, Studdert DM, Burstin HR, Orav EJ, Zeena T, Williams EJ (1999) Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care 38: 261–271

    Article  Google Scholar 

  52. Torsvall L, Akerstedt T (1988) Disturbed sleep while being oncall: an EEG study of ships’ engineers. Sleep 11: 35–38

    PubMed  CAS  Google Scholar 

  53. Wanzel K, Jamieson C, Bohnen J (1999) Complications on a general surgery service: incidence and reporting. Can J Surg 43: 113–117

    Google Scholar 

  54. Wiener E, Kanki B, Helmreich R (1993) Cockpit resource management. Academic Press, San Diego (CA) p 519

    Google Scholar 

  55. Wilkinson R, Edwards R, Haines E (1996) Performance following a night of reduced sleep. Psychonom Sci X: 471–472

    Google Scholar 

  56. Z’Graggen K, Wehrli H, Metzger A, Buehler M, Frei E, Klaiber C (1998) Complications of laparoscopic cholecystectomy in Switzerland: a prospective 3-year study of 10,174 patients. Swiss Association of Laparoscopic and Thoracoscopic Surgery [comments]. Surg Endosc 12: 1303–1310

    Article  PubMed  Google Scholar 

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Author information

Authors and Affiliations

  1. Surgical Technology and Safety Laboratory, University of Virginia, Post Office Box 800709, 22908-0709, Charlottesville, VA, USA

    J. F. Calland, R. B. Adams, C. G. Tribble, E. Foley & E. G. Chekan

  2. Department of Systems and Information Engineering, University of Virginia, School of Engineering and Applied Sciences, Thornton Hall, Post Office Box 400747, 22904-4747, Charlottesville, VA, USA

    S. Guerlain

Authors
  1. J. F. Calland
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  2. S. Guerlain
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  3. R. B. Adams
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  4. C. G. Tribble
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  5. E. Foley
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  6. E. G. Chekan
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Online publication: 14 May 2002

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Calland, J.F., Guerlain, S., Adams, R.B. et al. A systems approach to surgical safety. Surg Endosc 16, 1005–1014 (2002). https://doi.org/10.1007/s00464-002-8509-3

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  • DOI: https://doi.org/10.1007/s00464-002-8509-3

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