Human errors in surgery by dr dinesh bhu

HUMAN ERRORS IN SURGERY

Speaker Dr DineshInstitute of Medical Sciences,BHU

THE PERFORMANCE OF SURGICAL OPERATIONS to be the MOST complex psychomotor activity that human beings are called upon to perform.

• Willie King, age 51 with a history of diabetes, consented to a have a below knee amputation on his right foot. Surgeons amputated is left foot in error.

WHAT IS HUMAN ERROR ?

An error is the failure of a planned action to be completed as intended (error of execution) or the use of the wrong plan to achieve an aim (error of planning).

The 1999 Institute of Medicine Report suggested medical errors are the eighth leading cause of death in the United States, causing up to 100,000 deaths annually

ONION MODEL OF SURGICAL SYSTEM

Team factors

HUMAN

ERRORS

Situational factors

Organizational factors

Personal factors

Task factorsPatient factors

Organizational

Personal and

equipments

Documentations

Timing

New members

Situational

interruptions

Equipments

designDistractions

Team factors

Dealing with unexpected

events

confidence

communication

Individual factors

fatigueperformance

Mentally sound

Task factors

InformationClear protocols

Patient factors

Co morbidity

Disease severity

Anatomic variations

Why Do Events Happen?

Sometimes multiple errors line up to allow

a significant event or injury

to occur

Sometimes an error occurs, but an event or injury is prevented by an internal system of checks

Significantevents orinjuries

From Managing the Risks of Organizational Accidents, James Reason

TYPES OF ERRORS

Skill based

Rule based

Knowledge based

Faulty execution of a task

Misdiagnosis leading to wrong rule

Due to incomplete or incorrect knowledge

HOW TO LOOK THE ERRORS?

Person approach- old type - only doctor

is responsible - less chance

of learning System approach – - whole system

is responsible - more chance

correction

The complexity should be reduced. Procedures should be standardized

as much as possible. The information process should be

optimized by using checklists and reminders.

Equipment and instruments should be improved and standardized.

Training should be adequate

HOW TO AVOID ERRORS ?

HOW TO AVOID ERRORS ?

Pay attention to detail- S T A R Proper communication Support each other

• Stop• Think• Act• Revie

w

TAKE HOME MESSAGE Human error is inevitable and

unavoidable. The systems approach is required to

significantly reduce the number of human errors in surgery.

The blaming culture should be rejected.

System should be less complex and standardized.

Training should be adequate

‘‘Fallibility is part of the human condition; We cant change the

human condition, but we can change the conditions under which people

work.”

THANK YOU