Most Surgical Adverse Events Result From Human Error

Tara Haelle

August 01, 2019

More than half of adverse events occurring during surgical procedures resulted from human error, and just over half of these errors were cognitive in nature, according to a quality improvement study published online yesterday in JAMA Network Open.

The researchers developed a tool for classifying human error and applied the tool on a weekly basis at three affiliate hospitals concurrently: a level I municipal trauma center, a quaternary care university hospital, and a US Veterans Administration hospital. They aimed to better understand behavioral drivers by examining both individuals' and teams' errors that led to adverse events.

"These findings could provide a basis for new approaches to cognitive training for surgeons and other health care practitioners to enhance the safety of surgical care delivery, approaches similar to those used in other high-risk industries, such as the aerospace industry," write James W. Suliburk, MD, of Baylor College of Medicine in Houston, Texas, and colleagues. 

The investigators developed and implemented a new tool that classified human performance deficiencies (HPDs) into five cognitive, technical, or team dynamic functions-related categories. The categories included execution; planning or problem solving; communication; teamwork; and rules violation.

Each week, a morbidity and mortality conference at the hospital brought together all attending faculty, residents, and surgical trainees to discuss and categorize the previous week's adverse events from general surgery, acute care surgery, surgical oncology, cardiothoracic surgery, vascular surgery, and abdominal transplantation services. Before these meetings began, surgeons received training in using the HPD classifier tool.

Among 5365 patients, 3.4% (182 patients) experienced an adverse event during a surgical operation. Adverse events occurred in another six patients during nonoperative treatment. 

Human error was responsible for more than half of these adverse events (56.4%). Most of the errors (51%) were related to execution whereas 29.3% were related to planning or problem solving, 12.8% to communication, 4.8% to teamwork, and 3.2% to rules violation. Most of the human errors occurred during the surgery itself (54.8%) whereas 8% occurred preoperatively and 26.6% postoperatively.

Among the adverse events arising from human performance deficiencies, 51.6% of the errors were cognitive, "most commonly presented as cognitive errors in execution of care or in case planning or problem solving," the authors report.

Common cognitive errors in execution included lack of attention, memory lapses, or lack of recognition of a problem, which together comprised nearly one third (31.8%) of the cognitive errors. Another 19.8% resulted from cognitive bias in care planning or problem solving.

"Given that we and others report a current surgical adverse event rate of nearly 5%, our data suggest that more than 400,000 potentially preventable adverse events associated with HPDs occur among the nearly 17 million inpatient and ambulatory operative procedures performed in the United States annually," the authors write. "Similarities between adverse event rates in our study compared with previous studies suggest that human error remains a significant unresolved cause of adverse events in health care delivery."

Half the errors occurred in isolation whereas the other half clustered with other HPDs. Among clustered HPDs, cognitive errors again occurred most often, frequently paired with technical errors, and most of the errors were categorized as relating to planning or problem solving.

"These findings suggest the dominant role of cognitive error as a root cause of surgical adverse events, even those that would appear to be technical rather than cognitive in nature," the authors write. Consequently, they say, quality-improvement interventions to reduce errors need to go beyond existing systems-based strategies, particularly to address the large proportion of cognitive errors.

"It is interesting that lack of recognition was the most prevalent cognitive error and was classified in 19% of the HPD subclassifications, potentially reflecting the paradox that the most common dangers to patient safety are those that are initially unrecognized," the authors note. "This paradox raises important challenges for cognitive training."

Another challenge is burnout from increasing use of checklists (the authors refer to it as a "checklist burnout syndrome"). The investigators promote more cognitive training, such as exercises that "could involve simulated playbacks of real-life scenarios taken from our situation, background, assessment and recommendation anthology, similar to training performed in the aviation and aerospace industries," they write.

The authors have disclosed no relevant financial relationships.

JAMA Network Open. Published July 31, 2019. Full text

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