J. Suliburk1, C. Ryan1, Q. Buck1, C. Pirko1, N. Massarweh1, N. Barshes1, S. Awad1, S. R. Todd1, H. Singh2, T. Rosengart1 1Baylor College Of Medicine,Department Of Surgery,Houston, TX, USA 2Baylor College Of Medicine,DeBakey VA Medical Center For Innovations In Quality, Effectiveness And Safety / Department Of Internal Medicine,Houston, TX, USA
Introduction: Surgical quality improvement efforts have largely focused on data registries and process improvement strategies to overcome the role of human performance deficiencies (HPD) in catalyzing adverse outcome. Limited data are available in quantifying the prevalence and types of HPD in surgical complications. The purpose of this prospective study was to develop and deploy a novel taxonomy tool for analyzing cognitive, technical and team HPD during the provision of surgical care to understand how to improve safety and quality.
Methods: A prospective multicenter study involving 3 adult affiliate hospitals (level 1 trauma center, quaternary care university hospital and a VA hospital) at a large academic medical center was conducted over a 6-month interval in 2018. An HPD tool was developed through systematic literature review according to PRISMA guidelines followed by Delphi consensus among medical error experts. This tool classified HPD into 5 major categories related to cognitive, technical and team dynamic functions (Table). Training of all surgeons in error taxonomy and categorization occurred thru an initial 2-week run-in period. We then used the tool in weekly concurrent reporting of complications to categorize HPDs for all major adverse surgical outcomes across our 3 study site quality improvement conferences. Surgeons self-assigned preliminary HPD classification to case complications, which were then adjudicated by a 3-person investigator panel following a service-wide case presentation and discussion.
Results: 5365 cardiothoracic, surgical oncology, transplant, elective general surgery, acute care surgery, and vascular surgery cases were analyzed. The overall major complication rate was 5% (188 complications). Of these, 56% (n = 106) were HPD-related: 50% execution error, 31% cognitive dissonance, 13% communication error, 4% teamwork error, and 5% rules violation. The average number of HPDs per case was 1.8 ± 0.9. The frequency and distribution of HPDs was similar across sites, with cognitive bias in decision of care being most common (HPD Class IA.3) subtype, followed by recognition error (HPD Class IIA). HPD most commonly occurred postoperatively (58%), followed by intraoperatively (32%) and preoperatively (10%).
Conclusion: HPD was identified in over half the instances of major surgical complications at a major academic medical center, most typically related to cognitive dissonance and execution of care. The prevalence of these HPDs suggests opportunity for enhanced education and training to reduce the incidence of HPD contributing to adverse outcomes. The newly developed taxonomy provides a framework to facilitate quality improvement in understanding human error in surgery.
