Surgical never events and contributing human factors

Abstract

Introduction We report the first prospective analysis of human factors elements contributing to invasive procedural never events using a validated Human Factors Analysis and Classification System (HFACS). Methods From 8/2009 - 8/2014 surgical and invasive procedural “Never Events” (retained foreign object, wrong site/side procedure, wrong implant, wrong procedure) underwent systematic causation analysis promptly after the event. Contributing human factors were categorized using Reason's 4 levels of error causation and 161 HFACS subcategories (nano-codes). Results During the study approximately 1.5 million procedures were performed and 69 never events were identified. A total of 628 contributing human factors nano-codes were identified. Action-based errors (n=260) and preconditions to actions (n=296) accounted for the majority of the nano-codes across all four types of events, with individual cognitive factors contributing half of the nano-codes. The most common action nano-codes were confirmation bias (n=36) and failed to understand (n=36). The most common pre-condition nano-codes were channeled attention on a single issue (n=33) and inadequate communication (n=30). Conclusion Targeting quality and system improvement interventions addressing cognitive factors and team resource management as well as perceptual biases may reduce errors and further improve patient safety. These results delineate targets to further reduce never events from our healthcare system.

Debunking the myth that the majority of medical errors are attributed to communication

“…The majority of medical errors were comprised of knowledgebased mistakes and delays in care, 14 as well as human failures in clinical assessment, clinical reasoning and medical decision making. 8,[14][15][16][17][18][19][20][21][22][23][24][25] Failings in assessment and diagnosis typically included errors of judgement. 16,[24][25][26][27][28] Yamada et al 25 observed 780 algorithmdriven tasks and found that 194 of them (error rate of 23%) were completed incorrectly.…”

A Network Analysis of Perioperative Communication Patterns

“…Additionally, researchers studied approximately 1.5 million procedures between August 2009 and August 2014. After reviewing documentation for 69 surgical and invasive procedure never events (wrong procedure, wrong site, retained foreign object, wrong implant), they found that inadequate communication was a common behavioral factor …”

Human factors awareness and recognition during multidisciplinary team meetings

“…The human factors analysis and classification system (HFACS) expands on these domains and has been used to evaluate and improve safety across many different healthcare settings including "near miss" analysis and postgraduate surgical examinations. [14][15][16][17] This model is widely used in aviation to explain the layers of defence and how accidents happen because the "holes in the Swiss cheese." Pilots are trained in distraction management.…”

“…Human failures can be readily categorised into four main domains or levels and form the basis of the well‐known Swiss cheese model of medical error: the influence of the employing organisation, preconditions to unsafe acts (including personal factors such as fatigue), unsafe supervision and unsafe acts themselves (summarised in Table ). The human factors analysis and classification system (HFACS) expands on these domains and has been used to evaluate and improve safety across many different healthcare settings including “near miss” analysis and postgraduate surgical examinations . This model is widely used in aviation to explain the layers of defence and how accidents happen because the “holes in the Swiss cheese.” Pilots are trained in distraction management.…”