Simple human error causes more than half of all surgical mistakes and medical adverse events, according to the findings of a new study.
Common causes of most surgical errors are a lack of attention or memory lapses, researchers from Baylor College indicate in findings published late last month in the medical journal JAMA Network Open.
Researchers conducted a quality improvement study at three affiliate hospitals: a municipal trauma center, a university hospital, and a U.S. Veterans Administration Hospital. The focus was designed to better understand behaviors by surgeons and teams that lead to adverse events, including human errors.
The study included more than 5,300 surgeries, which were associated with 188 adverse events that were recorded. Researchers focused on various categories of errors, including problems with surgery execution, planning or problem solving, communication, teamwork, and rules violation.
A little more than half, 56%, of the adverse events were caused by human error, according to their findings. More than half of the errors were related to execution of the surgery, but about 30% were linked to difficulties with planning or problem solving. Only about 3% were linked to surgeons simply ignoring or failing to follow surgical rules.
Roughly half of the errors occurred during surgery and about one-quarter occurred postoperatively. Another 8% of errors occurred before the surgery during the preoperative stage.
About half of the errors occurred in isolation, meaning they were the only mistake made, while the other half occurred along with other human errors, the researchers found.
Of the adverse events caused by human error, half of those were caused by cognitive errors leading to surgical mistakes. Cognitive errors included things like a lack of recognition of a problem, lack of attention, memory lapses, or a bias in care planning or problem solving.
The study noted the healthcare system reports a surgical adverse event rate of 5% in the United States. That means there are 400,0000 potentially preventable adverse events linked to human error occurring among the nearly 17 million surgeries performed in the U.S. each year.
Researchers emphasized human error is a significant unresolved cause of adverse events in health care and steps should be taken to help reduce adverse events, including training and focus on surgical mistakes. This can also include exercises that focus on simulated playbacks of real-life problems occurring during surgery and training surgeons to recognize potential dangers to the patient.
Study authors hope the new tools used to identify and classify adverse events and errors occurring during surgery can help hospitals approach human error in a different way to enhance patient safety and surgical care.