Surgical never events and contributing human factors

Area of Science:

• Patient Safety
• Human Factors Engineering
• Medical Error Analysis

Background:

• Prospective analysis of human factors contributing to invasive procedural never events.
• Utilized the validated Human Factors Analysis and Classification System (HFACS).

Purpose of the Study:

• To systematically analyze the root causes of invasive procedural never events.
• To identify contributing human factors using a detailed classification system.

Main Methods:

• Analysis of operative and invasive procedural "Never Events" from August 2009 to August 2014.
• Systematic causation analysis using the Human Factors Analysis and Classification System (HFACS) and Reason's 4 levels of error causation.
• Categorization of contributing human factors into 161 HFACS subcategories (nano-codes).

Main Results:

• Identified 69 never events out of approximately 1.5 million procedures.
• Cataloged 628 contributing human factors nano-codes.
• Action-based errors and preconditions to actions constituted the majority of nano-codes, with cognitive factors comprising half. Common issues included confirmation bias, failure to understand, channeled attention, and inadequate communication.

Conclusions:

• Targeting cognitive factors, team resource management, and perceptual biases can decrease errors and improve patient safety.
• Identified specific targets for healthcare systems to further reduce never events.
• Emphasizes the importance of human factors in preventing adverse patient outcomes.