Surgical never events and contributing human factors

Cornelius A. Thiels, Tarun Mohan Lal, Joseph M. Nienow, Kalyan S Pasupathy, Renaldo Blocker, Johnathon M. Aho, Timothy Ian Morgenthaler, Robert R. Cima, Susan Hallbeck, Juliane Bingener

Research output: Contribution to journalArticle

32 Citations (Scopus)

Abstract

Introduction We report the first prospective analysis of human factors elements contributing to invasive procedural never events by using a validated Human Factors Analysis and Classification System (HFACS). Methods From August 2009 to August 2014, operative and invasive procedural Never Events (retained foreign object, wrong site/side procedure, wrong implant, wrong procedure) underwent systematic causation analysis promptly after the event. Contributing human factors were categorized using the 4 levels of error causation described by Reason and 161 HFACS subcategories (nano-codes). Results During the study, approximately 1.5 million procedures were performed, during which 69 never events were identified. A total of 628 contributing human factors nano-codes were identified. Action-based errors (n = 260) and preconditions to actions (n = 296) accounted for the majority of the nano-codes across all 4 types of events, with individual cognitive factors contributing one half of the nano-codes. The most common action nano-codes were confirmation bias (n = 36) and failed to understand (n = 36). The most common precondition nano-codes were channeled attention on a single issue (n = 33) and inadequate communication (n = 30). Conclusion Targeting quality and interventions in system improvement addressing cognitive factors and team resource management as well as perceptual biases may decrease errors and further improve patient safety. These results delineate targets to further decrease never events from our health care system.

Original languageEnglish (US)
Pages (from-to)515-521
Number of pages7
JournalSurgery (United States)
Volume158
Issue number2
DOIs
StatePublished - Aug 1 2015

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Medical Errors
Statistical Factor Analysis
Causality
Patient Safety
Foreign Bodies
Communication
Delivery of Health Care

ASJC Scopus subject areas

  • Surgery

Cite this

Thiels, C. A., Lal, T. M., Nienow, J. M., Pasupathy, K. S., Blocker, R., Aho, J. M., ... Bingener, J. (2015). Surgical never events and contributing human factors. Surgery (United States), 158(2), 515-521. https://doi.org/10.1016/j.surg.2015.03.053

Surgical never events and contributing human factors. / Thiels, Cornelius A.; Lal, Tarun Mohan; Nienow, Joseph M.; Pasupathy, Kalyan S; Blocker, Renaldo; Aho, Johnathon M.; Morgenthaler, Timothy Ian; Cima, Robert R.; Hallbeck, Susan; Bingener, Juliane.

In: Surgery (United States), Vol. 158, No. 2, 01.08.2015, p. 515-521.

Research output: Contribution to journalArticle

Thiels, Cornelius A. ; Lal, Tarun Mohan ; Nienow, Joseph M. ; Pasupathy, Kalyan S ; Blocker, Renaldo ; Aho, Johnathon M. ; Morgenthaler, Timothy Ian ; Cima, Robert R. ; Hallbeck, Susan ; Bingener, Juliane. / Surgical never events and contributing human factors. In: Surgery (United States). 2015 ; Vol. 158, No. 2. pp. 515-521.
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