Analysis of technical surgical errors during initial experience of laparoscopic pyloromyotomy by a group of dutch pediatric surgeons

Abstract

This early series of LPM was associated with an appreciable execution error rate, largely due to the poor functionality of the specific instruments used for the procedure. Human factors identified by the external error modes played a subsidiary but important role, underscoring the importance of skills training and experience (proficiency-gain curve).

Surgical timing after chemoradiotherapy for rectal cancer, analysis of technique (STARRCAT): results of a feasibility multi-centre randomized controlled trial

“…Video recording and technical performance analysis using OCHRA have previously been used in clinical practice and training environments [7,[17][18][19][20]. We have shown that it is possible to expand such a methodology and to co-ordinate the recording of operations within a multi-centre trial.…”

Human Reliability Analysis of Cataract Surgery

“…The 10 external error modes can be divided into 2 groups: 1 to 6, which are procedural error modes, disrupting the correct sequence of procedural steps; and 7 to 10, which are executional error modes, implying incorrect manipulation of instruments and tissues. [9][10][11]13 Grouping errors in this manner determines the nature of corrective measures: procedural error modes may be reduced by initiating a standardized operative task sequence, while executional error modes may be minimized by practicing surgical skills. …”

“…11(p1216) This definition was agreed upon at the Bellagio Conference on Human Error and has been previously used in earlier Observational Clinical Human Reliability Assessment surgical studies. [9][10][11] Similar principles of error identification were applied to cataract surgery in this study, in which an error was defined as an action that was clearly not intended by the surgeon; an action that was not performed to a predetermined standard, as set by our panel of expert cataract surgeons; or an action that increased the likelihood of a negative consequence or was not within acceptable safety limits of the surgical procedure.…”

“…Better understanding of such errors could have a positive effect on learning, especially on the acquisition of technical skills. 9 This would enable us to refine our existing and future training and assessment systems by identifying underlying surgical performance error mechanisms among surgeons with varying levels of experience. Using the HRACS tool in this study, most errors identified were of the execution type (66.2%), suggesting that the surgeons were largely following the correct sequence of steps within the procedure most of the time, but failed to execute some of the component tasks adequately.…”

“…7 A modified version of the HRA tool, the Observational Clinical Human Reliability Assessment, has been applied to assess technical skill in laparoscopic cholecystectomy and other general surgical procedures; HRA was subsequently established as a validated system of objective surgical skill assessment. [9][10][11][12] The aim of this study was to evaluate the HRA process in identifying the frequency and pattern of technical errors observed during phacoemulsification cataract extraction performed by surgeons with varying levels of operative experience.…”