Researchers from Rochester, Minn.-based Mayo Clinic used human factors analysis, a system originally developed to investigate military plane crashes, to identify four categories of human behavior that contribute to major surgical errors.
The researchers identified 69 never events among 1.5 million invasive procedures over five years and detailed why they happened. Then they used human factors analysis to code the human behaviors involved to find the environmental, organizational, job and individual characteristics that led to the surgical errors.
They grouped the errors into four levels, made up of multiple factors. They are:
- Preconditions for action. This includes poor hand-offs, distractions, overconfidence, stress, mental fatigue and poor communication.
- Unsafe actions, including bending or breaking rules or failing to understand before acting.
- Oversight and supervisory factors, such as inadequate supervision, staffing deficiencies and planning problems.
- Organizational influences. This could be culture or operational processes.
"What it tells you is that multiple things have to happen for an error to happen," Juliane Bingener, MD, a gastroenterologic surgeon at Mayo Clinic, said. "We need to make sure that the team is vigilant and knows that it is not only OK but is critical that team members alert each other to potential problems. Speaking up and talking advantage of all the team's capacity to prevent errors is very important, and adding systems approaches as well."