Human behavior behind most surgical errors

Major surgical errors often involve a series of nine separate missteps--including overconfidence of surgeons and nurses as well as a focus on the minute details of the procedure that cause clinicians to lose sight of the big picture--according to a study conducted by researchers at the Mayo Clinic.

The research, published in the journal Surgery, examined surgical "never events," which include performing the wrong procedure on a patient or leaving a surgical instrument inside a patient's body, that should never happen and yet continue to occur at facilities across the United States. 

The research team, led by Julianne Bingener, M.D., a gastroenterologic surgeon at Mayo Clinic, used human factors analysis to identify 69 never events, including surgery on the wrong person, the wrong site or the wrong side of body, among 1.5 million invasive procedures performed over five years at the organization and detailed why each occurred. They found 628 human factors contributed to the errors overall, roughly four to nine per event.

Nearly two-thirds of the Mayo never events occurred during relatively minor procedures such as anesthetic blocks, line placements, interventional radiology procedures, endoscopy and other skin and soft tissue procedures

The Mayo Rochester campus rate of never events over the period studied was roughly 1 in every 22,000 procedures. A 2013 study estimated that the rate of such never events in the United States is almost twice the number identified in the Mayo research, approximately 1 in 12,000 procedures.

Multiple missteps lead to errors

The research indicates multiple missteps must occur for a medical error to happen, Bingener said in a study announcement. The research team identified four major levels of errors and several potential causes:

  • Preconditions for action, such as poor hand-offs, distractions, overconfidence, stress, mental fatigue and inadequate communication.
  • Unsafe actions, such as bending or breaking rules or failing to understand them. This category of errors includes confirmation bias, in which clinicians convince themselves they are seeing what they think they should be seeing.
  • Oversight and supervisory factors, such as inadequate supervision, staffing deficiencies and planning problems.
  • Organizational influences, such as problems within the organization'sl culture or operational processes.

"We need to make sure that the team is vigilant and knows that it is not only OK but is critical that team members alert each other to potential problems. Speaking up and taking advantage of all the team's capacity to prevent errors is very important [as well as] adding systems approaches," she said in the announcement.

Steps to prevent never event errors

To prevent these errors, Mayo Clinic follows the Joint Commission's universal protocol to conduct a team briefing and huddle before a surgery starts and to pause before the surgeon makes the first incision. Surgical teams also use the World Health Organization's recommended safety checklist for debriefings. To make sure the team doesn't leave surgical sponges in patients, Mayo Clinic now uses a bar-code scanning system to count and track sponges.

Another study on reducing never events was published in this month's issue of the Joint Commission Journal on Quality and Patient Safety. Authors J. Matthew Austin, Ph.D., and Peter J. Pronovost, M.D., Ph.D., from the Armstrong Institute for Patient Safety and Quality, part of Johns Hopkins Medicine in Baltimore, reviewed the evolution and data collection of never events, and suggested the healthcare industry can take the following steps to improve the tracking and reporting of these events:

  • Agree on standard definitions of never events.
  • Establish standards for the accuracy of never events derived from administrative data and relative to chart review and publicly report the accuracy of these measures.
  • Report the number and severity of never events in a transparent manner, following the lead of the state of Minnesota's reporting system.
  • Establish mechanisms to share best practices for reducing all types of never events.

"Never events are occurring with a troubling frequency," the authors said in an announcement. "Many of these events, such as wrong-patient surgery, are deemed 'fully preventable'. If we hope to see reductions in the frequency of these events, we need to change the decade-long decentralized approach of collect, report andimprove to an approach that entails standardized definitions of events, greater transparency of performance and collective learnings and accountability to drive performance forward."

To learn more:
- here's the Mayo study abstract and study announcement
- read the Joint Commission study and announcement
- check out the 2013 study in Surgery

 

 

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