Errors enacted during endoscopic surgery—a human reliability analysis

doi:10.1016/S0003-6870(98)00016-7

Applied Ergonomics

Volume 29, Issue 6, 4 December 1998, Pages 409-414

https://doi.org/10.1016/S0003-6870(98)00016-7 Get rights and content

Abstract

The aim of the study was to document the nature and incidence of surgical errors enacted during laparoscopic surgery in order to direct future research and surgical training. A modified Human Reliability Analysis (HRA) approach, based on direct observation, was adopted to categorise and record errors encountered during the practice of laparoscopic cholecystectomy. This study confirmed the applicability and usefulness of an observational methodology in the assessment of human error in endoscopic surgical performance. The study identified aspects of the design and usage of instruments, surgical training and the differences between tasks which needed further directed research in order to identify underlying performance shaping factors (PSFs) and so reduce error rates.

Introduction

Laparoscopic or keyhole surgery is the practice of surgery using the smallest practical incision to gain access to internal organs and carry out surgical procedures. The small size of incisions means that the control of surgical instruments and the visual display of the surgical workspace has to take place remotely, outside the patient’s body. This arrangement creates several restrictions for the surgeon. The instruments have only four degrees of freedom with a diminished tactile feedback. The visual display system only provides a two dimensional image which is captured from the operative field by an endoscope. This image is remote from the location of motor control, where manipulations occur, and with the current design of theatre workspace, the visual axis of the surgeon is not aligned with the motor axis of the instrument and forearm.

In almost all surgical studies, surgical performance has been investigated in terms of the outcome and complications that may arise as a result of surgical error (Cuschieri et al, 1991; Southern Surgeons Club, 1991; Airan et al, 1992; Schumpf, 1994). However, these morbidity data do not provide prescriptive information of how errors are enacted and cannot specify how the performance of a procedure can be improved. A detailed study of the errors is required to identify the performance shaping factors (PSFs) which underlie these errors, and their resultant surgical complications, inorder that corrective action to reduce the likelihood of recurrence can be taken.

The aim of this study was to identify the errors made by surgeons undertaking laparoscopic surgical procedures to direct more specific future research into the PSFs affecting surgical performance.

Section snippets

Materials and methods

The study of human error in industry has typically involved the use of simulation exercises to predict the occurrence of errors in real circumstances (Meister, 1992). However, any prediction study needs further validation by observation and collection of data from the workplace in order to confirm the accuracy of the prediction in reality. In this study, a modified human reliability assessment (HRA) approach was applied to evaluate task performance in minimal access surgery. HRA is the

Overall error data

A total of 189 separate errors were recorded during the observation of 20 laparoscopic cholecystectomies. None of the errors recorded gave rise to any post operative complications in any of the 20 patients and all were discharged from hospital within 48 h of the operation. Of the total 189, 116 were intrastep errors whilst 73 were interstep errors. More of the intrastep errors (28%) needed corrective action than did interstep errors (9%). The most serious consequence of any of the observed

Discussion

Given the significant number of errors recorded in this relatively small sample, the study has shown that it is possible to use an observational data capture technique to study human error in laparoscopic surgery. The majority of the errors recorded were intrastep errors associated with the motor control of instruments and these gave rise to the majority of errors needing corrective action. The study recorded a high frequency of interstep errors (39% of the total number of errors). These high

Acknowledgements

This work was supported by a grant to Prof A. Cuschieri from the Dundee Teaching Hospitals NHS Trust.

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There are more references available in the full text version of this article.

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Errors enacted during endoscopic surgery—a human reliability analysis

Abstract

Introduction

Section snippets

Materials and methods

Overall error data

Discussion

Acknowledgements

Retrospective and prospective multi-institutional laparoscopic cholecystectomy study organised by Society of American gastrointestinal endoscopic surgeons

Surg Endosc

The European experience with laparoscopic cholecystectomy

Am J Surg