Nature of Human Error
- 1 November 2006
- journal article
- review article
- Published by Ovid Technologies (Wolters Kluwer Health) in Annals of Surgery
- Vol. 244 (5), 642-648
- https://doi.org/10.1097/01.sla.0000243601.36582.18
Abstract
As the attitude to adverse events has changed from the defensive "blame and shame culture" to an open and transparent healthcare delivery system, it is timely to examine the nature of human errors and their impact on the quality of surgical health care. The approach of the review is generic rather than specific, and the account is based on the published psychologic and medical literature on the subject. Rather than detailing the various "surgical errors," the concept of error categories within the surgical setting committed by surgeons as front-line operators is discussed. The important components of safe surgical practice identified include organizational structure with strategic control of healthcare delivery, teamwork and leadership, evidence-based practice, proficiency, continued professional development of all staff, availability of wireless health information technology, and well-embedded incident reporting and adverse events disclosure systems. In our quest for the safest possible surgical health care, there is a need for prospective observational multidisciplinary (surgeons and human factors specialists) studies as distinct for retrospective reports of adverse events. There is also need for research to establish the ideal system architecture for anonymous reporting of near miss and no harm events in surgical practice.Keywords
This publication has 42 references indexed in Scilit:
- The Eindhoven laparoscopic cholecystectomy training course—improving operating room performance using virtual reality training: results from the first E.A.E.S. accredited virtual reality trainings curriculumSurgical Endoscopy, 2005
- Reducing errors in the operating roomSurgical Endoscopy, 2005
- What makes an error unacceptable? A factorial survey on the disclosure of medical errorsInternational Journal for Quality in Health Care, 2004
- Hindsight bias, outcome knowledge and adaptive learningQuality and Safety in Health Care, 2003
- Lest We Forget the SurgeonSurgical Innovation, 2003
- Hindsight != foresight: the effect of outcome knowledge on judgment under uncertaintyQuality and Safety in Health Care, 2003
- THE QUALITY MANAGEMENT SYSTEM AS A TOOL FOR IMPROVING STAKEHOLDER CONFIDENCEQuality Assurance, 2000
- The Evolution of Crew Resource Management Training in Commercial AviationThe International Journal of Aviation Psychology, 1999
- The alarm problem and directed attention in dynamic fault managementErgonomics, 1995
- “Either a medal or a corporal”: The effects of success and failure on the evaluation of decision making and decision makersOrganizational Behavior and Human Decision Processes, 1989