Analysis of Human Performance Deficiencies Associated With Surgical Adverse Events

Abstract

Importance: Potentially preventable adverse events remain a formidable cause of patient harm and health care expenditure despite advances in systems-based risk-reduction strategies.

Objective: To analyze and describe the incidence of human performance deficiencies (HPDs) during the provision of surgical care to identify opportunities to enhance patient safety.

Design, setting, and participants: This quality improvement study used a new taxonomy to inform the development and implementation of an HPD classifier tool to categorize HPDs into errors associated with cognitive, technical, and team dynamic functions. The HPD classifier tool was then used to concurrently analyze surgical adverse events in 3 adult hospital affiliates-a level I municipal trauma center, a quaternary care university hospital, and a US Veterans Administration hospital-from January 2, 2018, to June 30, 2018. Surgical trainees presented data describing all adverse events associated with surgical services at weekly hospital-based morbidity and mortality conferences. Adverse events and HPDs were classified in discussion with attending faculty and residents. Data were analyzed from July 9, 2018, to December 23, 2018.

Main outcomes and measures: The incidence and primary and secondary causes of HPDs were classified using an HPD classifier tool.

Results: A total of 188 adverse events were recorded, including 182 adverse events (96.8%) among 5365 patients who underwent surgical operations and 6 adverse events (3.2%) among patients undergoing nonoperative treatment. Among these 188 adverse events, 106 (56.4%) were associated with HPDs. Among these 106 HPD adverse events, a total of 192 HPDs (mean [SD], 1.8 [0.9] HPDs per HPD event) were identified. Human performance deficiencies were categorized as execution (98 HPDs [51.0%]), planning or problem solving (55 HPDs [28.6%]), communication (24 HPDs [12.5%]), teamwork (9 HPDs [4.7%]), and rules violation (6 HPDs [3.1%]). Human performance deficiencies most commonly presented as cognitive errors in execution of care or in case planning or problem solving (99 of 192 HPDs [51.6%]). In contrast, technical execution errors without other associated HPDs were observed in 20 of 192 HPDs (10.4%).

Conclusions and relevance: Human performance deficiencies were identified in more than half of adverse events, most commonly associated with cognitive error in the execution of care. These data provide a framework and impetus for new quality improvement initiatives incorporating cognitive training to mitigate human error in surgery.

Figure 1.. Analysis of Human Performance Deficiency Combinations Among 53 Clustered Human Performance Deficiency Events

The size of the circles indicates the frequency of each occurrence of a human performance deficiency. Each line represents 1 association.

Figure 2.. Human Performance Deficiency (HPD) Proximate Cause Analysis

Designations were made of a causative HPD (primary HPD) and secondary HPDs in adverse events with clustered HPDs. Orange circles indicate clusters with 1 secondary HPD; blue circles, clusters with 2 or more secondary HPDs. The size of the circles indicates the frequency of occurrence.