HUMAN ERROR PERSPECTIVES IN HEALTH CARE: IMPLICATIONS FOR IMPROVING PATIENT SAFETY IN THE OPERATING ROOM

A marker of surgical excellence is the ability to successfully manage errors and unexpected events during surgery. However, even experienced surgical teams can become mired by minor problems that disrupt surgical flow. As the number of minor events increase, the likelihood that the surgical team is able to cope with a major event decreases. Minor events appear to exert an additive effect by cumulatively eroding the limited compensatory resources of the surgical team. Unfortunately, little is known about the frequency and nature of surgical flow disruptions that actually impact surgical performance, making the development of interventions that effectively improve patient safety extremely onerous. However, research in other complex settings suggests that human error is often caused by a combination of active and latent failures, only the last of which is an unsafe act of an individual. Therefore, interventions that target underlying systemic factors are often more efficacious than approaches that focus exclusively on individual characteristics. In the present talk, the systems approach to understanding surgical error will be compared to more traditional person-focused approaches to error prevention. In addition, data demonstrating how the systems approach can be applied to empirically identify factors that impact surgical performance will be presented. The talk will conclude with a discussion of how a better understanding of the systemic factors that produce surgical errors might be used to develop effective evidenced-based patient safety programs.