Study: Half of adverse events are caused by human error

Residency Program Insider, September 10, 2019

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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

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