Elsevier

Surgery

Volume 144, Issue 4, October 2008, Pages 557-565
Surgery

Central Surgical Association
Human error, not communication and systems, underlies surgical complications

https://doi.org/10.1016/j.surg.2008.06.011Get rights and content

Objective

This study prospectively assesses the underlying errors contributing to surgical complications over a 12-month period in a complex academic department of surgery using a validated scoring template.

Background

Studies in “high reliability organizations” suggest that systems failures are responsible for errors. Reports from the aviation industry target communication failures in the cockpit. No prior studies have developed a validated classification system and have determined the types of errors responsible for surgical complications.

Methods

A classification system of medical error during operation was created, validated, and data collected on the frequency, type, and severity of medical errors in 9,830 surgical procedures. Statistical analysis of concordance, validity, and reliability were performed.

Results

Reported major complications occurred in 332 patients (3.4%) with error in 78.3%: errors in surgical technique (63.5%), judgment errors (29.6%), inattention to detail (29.3%), and incomplete understanding (22.7%). Error contributed more than 50% to the complication in 75%. A total of 13.6% of cases had error but no injury, 34.4% prolongation of hospitalization, 25.1% temporary disability, 8.4% permanent disability, and 16.0% death. In 20%, the error was a “mistake” (the wrong thing), and in 58% a “slip” (the right thing incorrectly). System errors (2%) and communication errors (2%) were infrequently identified.

Conclusions

After surgical technique, most surgical error was caused by human factors: judgment, inattention to detail, and incomplete understanding, and not to organizational/system errors or breaks in communication. Training efforts to minimize error and enhance patient safety must address human factor causes of error.

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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