Researchers from Baylor College of Medicine conducted a quality improvement study to assess the “incidence and causes of human error as a source of adverse events associated with surgical care” and “identify opportunities to enhance patient safety.”
Their findings, published recently in JAMA Network Open, are based on an analysis of 5,365 surgeries performed at three hospitals within a major academic medical center in which they identified 188 adverse events. Using this rate of surgical adverse events (approximately 5%, which aligns with what others have reported), the study’s authors estimate that “more than 400,000 potentially preventable adverse events associated with human error occur among the nearly 17 million inpatient and ambulatory operative procedures performed in the United States annually.”
In addition to quantifying the number of surgical errors, they also categorized them by type. As reported by Becker’s Hospital Review, researchers were “surprised to find that errors related to communication, teamwork and systems were relatively low. In contrast, over half of the errors were cognitive, involving lack of attention, lack of recognition and cognitive bias.”
A press release about the study offers insights into preventing these types of errors. In the release, the study’s senior author says, “Human error is considered inevitable, so the focus on reducing bad outcomes in medicine has been to build systems to mitigate the risks of human error… Instead of adding another checklist, we want to train people to be more in touch with their vulnerability to human performance deficiency.”
Becker’s summarizes the risk management opportunity like this: “The study suggests healthcare organizations should shift their focus to cognitive training and teach medical staff to recognize their own mental pitfalls.” As described in the study’s conclusion, such training “could involve simulated playbacks of real-life scenarios [like] training performed in the aviation and aerospace industries.”
MLMIC encourages all our insured surgeons to explore ways to enhance clinical decision-making and further their understanding of how cognitive processes impact the potential for error. “Top Risks of the Ambulatory Surgery Center,” our September 25 webinar in conjunction with HANYS, offers an educational opportunity and will deliver insight into issues that impact the care of surgical patients and how to mitigate these potential risks.
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