Human error was to blame for over half of the adverse events like deaths, infections, and surgical mistakes. These were recorded in a Texas college study of over 5,300 hospital surgeries.
The Baylor College of Medicine in Houston examined 5,365 surgeries at three hospitals in 2018. Of the 188 adverse events recorded in the study, 106 were due to human error.
More training needed to prevent these surgical errors
The study led researchers to conclude doctors and other medical staff should be encouraged to undergo training to be more in touch with their vulnerability to mistakes.
“We have to train people to listen to the voice in the back of their head,” said Dr. James Suliburk, associate professor of surgery at Baylor College.
Adverse events included death, infection, bleeding, neurological outcomes and hospital readmission.
The college studied surgeries at a level I municipal trauma center, a quaternary care university hospital and a United States Veterans Administration hospital from Jan. 2 - June 30, 2018.
(Medical care generally is divided into four levels: primary care, secondary care, tertiary care and quaternary care, related to the complexities of cases and skills of providers, according to verywellhealth, a medical topics website.)
The study examined operations performed by the general surgery, acute care surgery, surgical oncology, cardiothoracic surgery, vascular surgery and abdominal transplant services that occurred at the three hospitals in the six-month period.
Where human error occurs in surgery
In the study that shows human error associated with surgical errors, researchers identified five categories of human performance deficiencies:
- Planning or problem-solving
- Execution
- Rules violation
- Communication
- Teamwork
Researchers found that more than half of the human performance deficiencies were cognitive errors. Cognitive errors were lack of attention, lack of recognition or memory lapse, along with cognitive bias. Cognitive bias are errors in thinking that affect decisions and judgments.
A conclusion from the study is that there is a need to provide medical staff with cognitive training. This training could help them recognize pitfalls in their thinking and in their work.
Another conclusion: potentially preventable adverse events remain a formidable cause of patient harm and health care expenditure. This, despite advances in strategies that focus on medical systems and risk reduction.
Some positive conclusions
The study showed lower-than-expected problems related to communication, teamwork and the kinds of systems that were used, researchers said.
That was positive, Suliburk said. He said it’s a sign that efforts to optimize communication, teamwork and safety in medical work have succeeded.
At Baylor, as at similar facilities, medical staff meet weekly to review procedures that resulted in adverse events. They identify potential mistakes, as well as better approaches that could have been taken. Researchers in this study used a process like this to analyze human errors associated with the adverse outcomes found in the 5,365 surgeries.
Extrapolating, researchers said that approximately 17 million surgical procedures are done in the U.S. each year. If the adverse outcome rate is about 5 percent and half of those are due to human error, as seen in the Baylor study and in other studies, it would mean that about 400,000 adverse outcomes could be prevented each year.
Contact the Cherundolo Law Firm in Syracuse and central New York today for help with cases involving human error associated with surgical errors and for any other medical malpractice issues.
