A surgical error and/or mistake happens all the time, everyday. So, a recent quality-improvement study was done that looked into surgical adverse events that occurred at three different hospitals. The study involved 5,365 patients. The results showed that 3.4% (182 patients) had an adverse event during a surgical operation. Another six patients had adverse events during nonoperative treatment. The investigators found that one of the leading causes of adverse events was human performance deficiencies (human error). These were grouped into five major categories; execution (51%), planning or problem solving (29.3%), communication (12.8%), teamwork (4.8%), and rules violations (3.2%).
Types of Cognitive Issues Creating a Surgical Error
The study found that among these adverse events, 51.6% were classified as cognitive errors, or errors which were a result of execution of care or in case planning or problem solving. The common (31.8%) errors included lack of attention, memory lapses, or lack of a recognition of a problem. Another 19.8% were the result of cognitive bias in care planning or problem solving. When they extrapolate the errors out over the nearly 17 million surgical procedures each year in the U.S., they estimate as many as 400,000 potentially preventable adverse events occurred as a result of these cognitive deficiencies.
The most significant part of this study is the fact that the most prevalent cognitive error was lack of recognition (19% of the adverse events). It is a scary problem in itself to think that errors occur because a medical provider doesn’t recognize a problem. In the case of something going wrong doing surgery, we all hope the surgeon will be able to address it.
The study ends by suggesting that hospitals and other medical organizations need to shift away from just trying to fix system-based errors. Instead they should address issues from a different perspective. Therefore, the researchers suggest promoting cognitive training. For example, playing back real-life scenarios of medical situations, similar to the way the aerospace industry trains people.
