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Mayo Clinic researchers have discovered that 628 human factors contribute to surgical errors overall, roughly four to nine per event. (Photograph: Dmitry Kalinovsky/Shutterstock)
Jun 15, 2015 | News Americas

Variety of human factors contribute to surgical never events

by Surgical Tribune

ROCHESTER, Minn., USA: Major surgical errors are called "never events" because they should not happen, but do. Mayo Clinic researchers have identified 69 such never events among 1.5 million invasive procedures performed over five years and detailed the reasons for the occurrence of each. They discovered that 628 human factors contributed to the errors overall, roughly four to nine per event.

Using human factor analysis—a system first developed to investigate military aviation accidents, the researchers coded the human behaviors involved to identify any environmental, organizational, job and individual characteristics that led to the never events. They grouped errors into four levels that included dozens of factors.

The first category, preconditions for action, included poor handoffs, distractions, overconfidence, stress, mental fatigue and inadequate communication. Another category comprised unsafe actions, such as bending or breaking rules or failing to understand. This category includes perceptual errors, such as confirmation bias, in which surgeons or others convinced themselves they were seeing what they thought they should be seeing. Moreover, there were the categories of oversight and supervisory factors, including inadequate supervision and staffing deficiencies, as well as of organizational influences, that is, problems with organizational culture or operational processes.

The observed never events included performing the wrong procedure (24), performing surgery on the wrong site or wrong side of the body (22), inserting the wrong implant (5), or leaving an object in the patient (18). All of the errors analyzed occurred at Mayo Clinic; none were fatal.

The Mayo Rochester campus rate of never events over the period studied was roughly 1 in every 22,000 procedures. Because of inconsistencies in definitions and reporting requirements, it is difficult to find accurate comparison data, but a recent study based upon information in the National Practitioner Data Bank estimated that the rate of such never events in the U.S. is almost twice that in this report, approximately 1 in 12,000 procedures.

Nearly two-thirds of the Mayo never events occurred during relatively minor procedures, such as anesthetic blocks, line placements, interventional radiology procedures, endoscopy and other skin and soft-tissue procedures.

Medical teams are highly skilled and motivated, yet preventing never events entirely remains elusive, said senior study author Dr. Juliane Bingener-Casey, a gastroenterologic surgeon at Mayo Clinic. The finding that factors beyond "cowboy-type" behavior were to blame points to the complexity of preventing never events, she said.

"What it tells you is that multiple things have to happen for an error to happen," Bingener 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 taking advantage of all the team's capacity to prevent errors is very important, and adding systems approaches as well."

For example, to help prevent surgical sponges from being left in patients, Mayo Clinic implemented a sponge-counting system and uses that barcode-scanning system and vigilance by the surgical team to track sponges. Other preventive systems include application of the Joint Commission health care quality organization's Universal Protocol, team briefings and huddles before the start of surgery, a pause before the first incision is made, and debriefings using a World Health Organization-recommended safety checklist.

In addition to systems approaches and efforts to improve communication, attention should be paid to cognitive capacity, such as team composition, technology interfaces, time pressures and individual fatigue, the researchers said. The stakes are high for patients, physicians and hospitals, Bingener pointed out. "The most important piece is the patient perspective. You don't want a patient to have to experience a never event. The breach in trust that happens with that is the most important part," she stated.

Mayo Clinic is a nonprofit organization committed to medical research and education, and provides expert whole-person care to everyone who needs healing.

The study, titled "Surgical Never Events and Contributing Human Factors," was published online in the Surgery journal on May 29.

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