Study: Half of adverse events are caused by human error
Residency Program Insider, September 10, 2019
Want to receive articles like this one in your inbox? Subscribe to Residency Program Insider!
Baylor College of Medicine conducted an analysis examining surgeries over a six-month period that resulted in adverse events, and the ensuing data revealed that more than half of the events were caused by “human performance deficiencies.” The report was recently published in JAMA Network Open.
Researchers collected data on more than 5,300 surgical operations performed at three adult teaching hospitals. Of these surgeries, 188 resulted in adverse events, including death or major complications. Of the 188, 105 were due to human error.
“There are approximately 17 million surgical procedures performed in the United States each year. If the adverse outcome rate is about 5%, and half of those are due to human error, as seen in our cohort and reported in other studies, it would mean that about 400,000 adverse outcomes could be prevented each year,” said Todd Rosengart, MD, FACS, chair and professor of the Michael E. DeBakey Department of Surgery at Baylor and senior author of the paper.
The analysis further sorted the deficiencies causing the errors into categories. Researchers found that more than half of the errors were cognitive in nature, frequently involving lack of attention, lack of recognition, and/or cognitive bias.
At Baylor, weekly conferences are held with surgery residents, fellows, and faculty during which procedures that resulted in adverse events are reviewed, mistakes are identified, and attendees discuss how things could have been done differently. Moving forward, Baylor plans to use this research to inform the creation of a simulation-training course focused on avoiding cognitive errors.
Source: Baylor College of Medicine
Want to receive articles like this one in your inbox? Subscribe to Residency Program Insider!
Related Products
Most Popular
- Articles
-
- CMS seeks comment on quality measures
- Don't forget the three checks in medication administration
- Practice the six rights of medication administration
- The consequences of an incomplete medical record
- Nursing responsibilities for managing pain
- Note similarities and differences between HCPCS, CPT® codes
- Neurological checks for head injuries
- Q&A: Primary, principal, and secondary diagnoses
- ICD-10-CM coma, stroke codes require more specific documentation
- Skills of effective case managers
- E-mailed
-
- Establish an ongoing records review process with five easy steps
- Know the JCAHO's ongoing records review requirements
- Tip: Report drugs with HCPCS code, revenue code 636
- The pros and cons of geographic rounds
- Sneak peek: Evidence-based practices can help improve, enhance case management skills
- Know the medical gas cylinder storage requirements
- Know the JCAHO's ongoing records review requirements
- Hold a scavenger hunt to prepare for survey
- Clear up confusion surrounding observation services
- Assisted living home owner bills Medicaid from unlicensed facility
- Searched