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Human error, not communication and systems, underlies surgical complications
Peter J Fabri1, José L Zayas-Castro
1University of South Florida College of Medicine, Tampa, FL 33612, USA. pfabri@health.usf.edu
Surgery
|October 14, 2008
Summary
Surgical complications are often due to human factors like poor judgment and inattention, not system failures. Improving surgical patient safety requires addressing these individual-level errors.
Area of Science:
- Surgical safety and quality improvement
- Medical error analysis
- Human factors in healthcare
Background:
- High reliability organizations suggest systems failures cause errors.
- Aviation industry reports highlight communication failures.
- No prior studies validated a classification system for surgical errors.
Purpose of the Study:
- To prospectively assess errors contributing to surgical complications.
- To analyze error types and severity in a complex academic surgery department.
- To utilize a validated scoring template for error classification.
Main Methods:
- Developed and validated a medical error classification system.
- Collected data on error frequency, type, and severity in 9,830 procedures.
- Performed statistical analysis for concordance, validity, and reliability.
Main Results:
- 78.3% of major complications involved error, primarily surgical technique (63.5%), judgment (29.6%), and inattention (29.3%).
- Human factors like judgment and inattention were the main drivers of error.
- System and communication errors were infrequently identified (2% each).
Conclusions:
- Surgical error is predominantly caused by human factors, not system or communication failures.
- Enhancing patient safety necessitates training focused on human factor causes of error.
- Targeting judgment, inattention, and understanding is crucial for reducing surgical complications.
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