Human factors contributing to surgical ‘never events’

Use of systems engineering has had a major impact on decreasing surgical never events. However, individual human factors also play a substantial and relevant role in determining whether and when never events occur.

This study from the Mayo Clinic, Rochester, Minnesota, is the first prospective analysis of human factor elements contributing to invasive procedural never events using a validated human Factors Analysis and Classification System.

During the study period (August 2009 to August 2014), some 1.5 million procedures were performed, during which 69 never events and 628 contributing human factors nano-codes were identified.

Action-based errors (260) and preconditions to actions (296) accounted for the majority of the nano-codes across four types of events (retained surgical item, wrong side/site procedure, wrong implant, wrong procedure), with individual cognitive factors contributing half of the nano-codes.

The most common action nano-codes were confirmation bias and failure to understand. The most common precondition nano-codes were channeled attention on a single issue and inadequate communication.

The results suggest that in addition to systems approaches to decrease never events, attention should be paid to the cognitive workload balance in the OR and procedural practices, the authors say.

—Thiels C A, Lal T M, Nienow J M, et al. Surgical never events and contributing human factors. Surgery. 2015;158(2):515-521.

http://www.surgjournal.com/article/S0039-6060(15)00315-3/abstract