How crises work: A model of error cause and effect in surgical practice
Petrut Gogalniceanu1, Nikolaos Karydis1, Nicos Kessaris1
1Guy's Hospital, Guy's and St.Thomas' NHS Foundation Trust, UK.
International Journal of Surgery (London, England)
|June 18, 2022
Summary
Surgical crises stem from system, skill, condition, or culture threats and are driven by performance, awareness, and rescue errors. Understanding these factors aids in managing safety-critical events in surgery.
Area of Science:
- Medical Safety
- Surgical Risk Management
- Healthcare Operations
Background:
- Surgical crises significantly impact patients, staff, and healthcare systems.
- The root causes and progression of surgical crises are not well understood.
- Current understanding often limited to post-event root-cause analyses.
Purpose of the Study:
- To develop a comprehensive model for surgical crises.
- To improve the reporting and management of safety-critical events in surgery.
Main Methods:
- A narrative review of safety literature concerning surgical crises.
- Thematic analysis of data from 133 sources.
- Consensus-based selection and inclusion of literature.
Main Results:
- Surgical care destabilizes in a stepwise manner, forming a crisis chain.
- Four categories of threats initiate crises: systems, surgeon skills, operational condition, and professional culture.
- Three types of errors drive crises: performance, awareness, and rescue errors.
Conclusions:
- Surgical crises are initiated by four threat categories and driven by three error types.
- These factors offer universal targets for safety interventions.
- The model provides new avenues for surgical crisis management.
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