Study Finds Cognitive Error Plays a Bigger than Expected Role in Surgical Adverse Events
Physician error in the surgical suite is particularly dangerous. A recently published study found that more than half the adverse events reviewed during the study were caused by human error.
Adverse and never events are terms used to describe medical errors and encounters that cause patient injury or death. They are a collection of medical errors that should “never” occur. But they do.
In a study published in JAMA Network Online, researchers from Baylor College of Medicine reviewed data from 5,365 surgical procedures. From these procedures, 188 adverse events were observed. Of these adverse events, more than half (56.4 percent) were due to human error.
Research data was collected from three teaching hospitals over a span of six months. Notes senior study author, Dr. Todd Rosengart, “There are approximately 17 million surgical procedures performed in the United States each year. If the adverse outcome rate is about 5 percent and half of those are due to human error, as seen in our cohort and reported in other studies, it would mean that about 400,000 adverse outcomes could be prevented each year.”
The study notes that surgical errors “remain a frequent cause of injury or death and source of potentially avoidable health care expenditure in the United States.” Further, although decades of work have gone into studying human error in the medical profession, there has been little forward movement in identifying what these study authors term “human performance deficiencies (HPDs).” Researchers also found that medical errors were generally consistent across the institution, and not more or less likely to occur to a particular surgical team.
The research team developed a tool for classifying errors made in surgical settings as a means of taking a more finely-grained approach to the identification and correction of fundamental physician errors that lead to patient injury. The study team hopes to create a simulation or training course to make surgical teams more aware of HPDs in the areas of:
- Planning or problem solving before or during the surgical event
- Execution of the procedure and related processes
- Rules violations
Adds Dr. Rosengart, “Instead of adding another checklist, we want to train people to be more in touch with their vulnerability to human performance deficiency,” he said. “We have to train people to listen to the voice in the back of their head.”
By identifying uniquely human factors, researchers hope to craft a better surgical team, instead of creating an additional cross-check process. In that regard, researchers note to err is human, and avoidance of errors lies with humans as well.
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