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Emergency Undocking in Robotic Surgery: A Simulation Curriculum
Published on: May 20, 2018
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Using simulation to improve root cause analysis of adverse surgical outcomes
Douglas P Slakey1, Eric R Simms, Kelly V Rennie
1Department of Surgery, Tulane University School of Medicine, 1430 Tulane Avenue, SL22, New Orleans, LA 70112, USA. dslakey@tulane.edu.
Summary
Simulation of adverse surgical outcomes (SAOs) offers a feasible method to investigate causality, identifying more system-based errors than traditional root cause analysis (RCA). This approach enhances patient safety by revealing actionable insights for system improvements.
Area of Science:
- Medical Simulation
- Patient Safety Research
- Surgical Outcomes Analysis
Background:
- Adverse surgical outcomes pose significant risks to patient safety.
- Conventional root cause analysis (RCA) has limitations in fully identifying systemic factors contributing to adverse events.
- There is a need for innovative methods to investigate surgical errors effectively.
Purpose of the Study:
- To develop and validate a simulation-based method for investigating the causality of adverse surgical outcomes.
- To compare the effectiveness of simulation of adverse outcomes (SAOs) with conventional RCA in identifying error sources.
Main Methods:
- Reviewed 631 closed malpractice claims, with three selected for detailed simulation.
- Developed simulation scenarios using medical and legal records, including participant scripting and simulated environments.
- Conducted simulations in a dedicated center, recording sessions and debriefing participants.
Main Results:
- SAOs identified more system errors and elucidated complex decision-making processes compared to conventional RCA.
- Simulation-based investigations focused more on systems-based errors rather than individual mistakes.
- Qualitative assessment of test subject decision-making provided insights into error pathways.
Conclusions:
- Simulation is a feasible and effective tool for investigating adverse surgical outcomes.
- SAOs identify root causes more amenable to systemic changes than conventional RCA.
- This method can facilitate corrective measures, reduce recurrence, and improve overall patient safety.
