Study identifies human performance deficiencies associated with adverse surgical events

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Study identifies human performance deficiencies associated with adverse surgical events

Press releases may be edited for formatting or style | August 01, 2019 Operating Room
HOUSTON - (July 31, 2019) - In the surgical setting, the concept "to err is human" could potentially be a matter of life and death. In an effort to identify surgical errors that could be prevented, researchers at Baylor College of Medicine conducted a comprehensive analysis of surgeries that resulted in adverse events over a six-month period and found that more than half were caused by human performance deficiencies. Their report appears today in the journal JAMA Network Open.

"Human error is considered inevitable, so the focus on reducing bad outcomes in medicine has been to build systems to mitigate the risks of human error," said Dr. Todd Rosengart, chair and professor of the Michael E. DeBakey Department of Surgery at Baylor and senior author of the paper. "There has been far less focus on teaching medical staff how to deal with their own human deficiencies or cognitive biases."

At Baylor, as at many medical centers, surgery residents, fellows and faculty hold weekly conferences to review procedures that resulted in adverse events and identify what mistakes may have been made and what could have been done differently. Investigators in this study used this conference to conduct a case-by-case analysis in real time to analyze the human errors associated with adverse outcomes.

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Researchers collected data from three adult teaching hospitals over six months, during which time more than 5,300 surgical operations were performed. Out of these procedures, adverse events occurred in 188 cases. Adverse events included death, major complications (infection, bleeding, neurological outcome) or non-routine events, such as hospital readmission. Of the 188 adverse event cases, human performance deficiencies were identified in 106, or more than 50 percent of cases.

"There are approximately 17 million surgical procedures performed in the United States each year. If the adverse outcome rate is about 5 percent and half of those are due to human error, as seen in our cohort and reported in other studies, it would mean that about 400,000 adverse outcomes could be prevented each year," said Rosengart, who also serves as president of the Society of Surgical Chairs.

Consistent with these findings, Rosengart and his colleagues found no significant differences in adverse events between the three hospitals or between different surgical service lines in their study, suggesting their outcomes are not unique to one institution.

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