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Researchers find multiple human factors pervasive in never events

Nurse Leader Insider, August 27, 2015

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Although systems management plays a distinct role in preventing never events, a new study shows that multiple human factors are at play when a never event occurs.

Researchers at the Mayo Clinic in Rochester, Minnesota recently published a study in Surgery that analyzed 69 never events occurring in 1.5 million invasive procedures, and found that 628 human factors contributed to those errors. Each event included approximately four to nine human factors.

The researchers utilized a method typically reserved for military plane crashes that specifically evaluates factors tied to environmental, organizational, job, and individual characteristics. Based on their analysis, researchers categorized the 628 human factors into four categories:
1. Preconditions for action (including overconfidence, stress, mental fatigue, or an inability to see the bigger picture)
2. Unsafe actions (including confirmation bias in which surgeons act on something they thought they saw)
3. Oversight (inadequate supervision or staffing deficiencies)
4. Organizational influences (cultural or systemic problems)

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