Nature of human error: implications for surgical practice

Abstract

Background: As the attitude to adverse events has changed from the defensive "blame and shame culture" to an open and transparent healthcare delivery system, it is timely to examine the nature of human errors and their impact on the quality of surgical health care.

Methods: The approach of the review is generic rather than specific, and the account is based on the published psychologic and medical literature on the subject.

Conclusions: Rather than detailing the various "surgical errors," the concept of error categories within the surgical setting committed by surgeons as front-line operators is discussed. The important components of safe surgical practice identified include organizational structure with strategic control of healthcare delivery, teamwork and leadership, evidence-based practice, proficiency, continued professional development of all staff, availability of wireless health information technology, and well-embedded incident reporting and adverse events disclosure systems. In our quest for the safest possible surgical health care, there is a need for prospective observational multidisciplinary (surgeons and human factors specialists) studies as distinct for retrospective reports of adverse events. There is also need for research to establish the ideal system architecture for anonymous reporting of near miss and no harm events in surgical practice.

FIGURE 1. Model of surgical proficiency zone (indicated by the shaded area): the proficiency-gain curves are specific to individual surgeons and to individual operations and indicate the number of interventions (of a specific nature) performed to reach proficient faultless execution in the automatic unconscious mode when the surgeon is able to perform the operation consistently well without having to think about it. The curve (i) represents the majority (with normal innate attributes for manual and hand-eye coordination tasks). The curve (ii) represents the naturally gifted surgeons (with above average innate attributes) who become master surgeons and perform at the top of the proficiency zone, whereas the curve (iii) represents the few who never reach proficient execution. The only scientific method for studying these proficiency-gain curves is by techniques involving observational clinical human reliability assessment (OCHRA).