Analysis of Human Performance Deficiencies Associated With Surgical Adverse Events

JAMA Network Open
James W SuliburkTodd K Rosengart

Abstract

Potentially preventable adverse events remain a formidable cause of patient harm and health care expenditure despite advances in systems-based risk-reduction strategies. To analyze and describe the incidence of human performance deficiencies (HPDs) during the provision of surgical care to identify opportunities to enhance patient safety. This quality improvement study used a new taxonomy to inform the development and implementation of an HPD classifier tool to categorize HPDs into errors associated with cognitive, technical, and team dynamic functions. The HPD classifier tool was then used to concurrently analyze surgical adverse events in 3 adult hospital affiliates-a level I municipal trauma center, a quaternary care university hospital, and a US Veterans Administration hospital-from January 2, 2018, to June 30, 2018. Surgical trainees presented data describing all adverse events associated with surgical services at weekly hospital-based morbidity and mortality conferences. Adverse events and HPDs were classified in discussion with attending faculty and residents. Data were analyzed from July 9, 2018, to December 23, 2018. The incidence and primary and secondary causes of HPDs were classified using an HPD classifier tool. A t...Continue Reading

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Citations

Dec 14, 2019·Academic Medicine : Journal of the Association of American Medical Colleges·Arthur R Derse
Jun 25, 2020·Revista do Colégio Brasileiro de Cirurgiões·Santiago Mc LoughlinOlle Ljungqvist
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Jan 31, 2020·AORN Journal·Mary Alice Anderson
Jul 6, 2020·Frontiers of Medicine·Allison J Navarrete-Welton, Daniel A Hashimoto
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May 25, 2021·The Journal of Thoracic and Cardiovascular Surgery·Alexander SchutzTodd K Rosengart
Aug 20, 2021·American Journal of Surgery·Laura D LeonardLauren Steward

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Software Mentioned

SAS
HPD

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