Central Surgical AssociationHuman error, not communication and systems, underlies surgical complications
Section snippets
Materials and methods
The study was conducted in 3 phases: development of the classification template, validation and reliability testing of the template/classification, as well as collection and analysis of error in surgical complications over a 12-month period.
Classification template
The final classification template (paper format) is included in Appendix 1. As is indicated in the template, the final error report asked for a brief description of the complication in free text and a numerical score of the severity of the complication (1—definite complication but no injury to patient and no prolongation of length of stay; 2—no injury but prolongation of hospitalization; 3—injury occurred with temporary disability; 4—injury occurred with permanent disability; 5—death.) It then
Discussion
This prospective study of error in operative therapy was designed to establish a standardized approach to human error in operation with the goal of providing a reliable metric for future studies of interventions to decrease surgical error. Error analysis can be performed in several ways. Most commonly, some form of self-reporting is used. Less often, specially trained individuals are assigned to review medical records to determine whether an error occurred and what type. Rarely, independent,
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