Conclusion
The documented and “accepted” incident rates in surgery are unacceptably high. Incident rates of 1–5% are generally accepted as a normal part of practice. Current morbidity and mortality reporting, while important, does not sufficiently examine or expose the active and latent errors that lead to adverse outcomes. Further. there is no process in place for systematically learning from surgical incident data so that appropriate changes can be incorporated in practice. Other high-risk industries have shown that process improvements, as well as the promotion of a culture of safety, can have a significant impact on an industry’s safety record. The establishment of surgical protocols and checklists has the potential to improve the standards of training and practice, as well as enhancing operating room communications. Data collection and analysis can identify latent errors that could be addressed through better training, device design, or surgical methods. Computerbased training could be instituted to allow surgeons to practice the perceptual, decision-making, and problemsolving skills that are a major part of surgery. These kinds of activities have been incorporated successfully into other industries and should also be applied to the practice of surgery.
Article PDF
Similar content being viewed by others
Avoid common mistakes on your manuscript.
References
Adamsen S, Hansen OH, Funch-Jensen P, Schulze S, Stage JG, Wara P (1997) Bile duct injury during laparoscopic cholecystectomy: a prospective nationwide series. J Am Coll Surg 184: 571–578
American College of Surgeons Health Policy and Advocacy Department. http://www.facs.org/dept/hpa/testimony/hpatest.html
American College of Surgeons National Trauma Registry System. http://www.facs.org/about_college/acsdept/trauma_dept/national_tracs/tracmenu.html
American College of Surgeons Oncology Group. http://www.acosog.org/
Andrews LB, Stocking C, Krizek T, Gottlieb L, Krizek C, Thomas V, Siegler M (1997) An alternative strategy for studying adverse events in medical care. Lancet 349: 309–313
Aston G (2000) Virginia high court favors peer review privacy. Am Med News 43: 5–6
Behrns K, Tsiotos G, Desouza N, Krishna M, Ludwig J, Nagorney D (1998) Hepatic steatosis as a potential risk factor for major hepatic resection. J Gastrointest Surg 2: 292–298
Senders JW (1994) Medical devices, medical errors and medical accidents. In: Bogner MS, Human error in medicine. Lawrence Erlbaum Associates. Hillsdale, NJ, USA. pp 159–177
Bogner S (2000) Quest for why: the systems approach to medical error institute for the study of medical error. Personal communication
Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG, Newhouse JP, Weiler PC, Hiatt HH (1991) Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I. N Engl J Med 324: 370–376
Chekan EG, Hayward TZ, Brody FJ, Purcell GP, Hayward K, Pappas TN, Eubanks WS (1998) Computers in surgical residencies. Curr Surg 55: 391–396
Cook R, Woods D, Miller C (1998) A tale of two stories: contrasting views of patient safety. Report from a workshop on Assembling the Scientific Basis for Progress on Patient Safety. Chicago, IL: National Health Care Council of the National Patient Safety Foundation at the AMA. pp. 1–74
Cook RI, Woods DD (1991) Same scene, different views: human performance in anesthesia. Human error in anesthesia. Ohio State University, USA
Cook RI, Woods DD, McDonald JS (1991) Human performance in anesthesia: a corpus of cases. Ohio State University, USA
Cooper JB, Gaba DM (1989) A strategy for preventing anesthesia accidents. Int Anesthesiol Clin 27: 148–152
Cooper JB, Newbower R (1975) The anesthesia machine: an accident waiting to happen. In: Pickett M, Triggs TJ (eds) Human factors in healthcare. DC Health & Co, Lexington, MA, USA, pp 345–358
Cooper JB, Newbower RS, Long CD, McPeek B (1978) Preventable anesthesia mishaps: a study of human factors. Anesthesiology 49: 399–406
Degani A, Wiener E (1994) On the design of flight deck procedures. Moffett Field, CA, USA, NASA Ames Research Center Contractor Report. pp 1–73
Dinges D, Pack F, Williams K, Gillen K, Powell J, Ott G (1997) Cumulative sleepiness, mood disturbance, and psychomotor vigilance performance decrements during a week of sleep restricted to 4–5 hours per night. Sleep 20: 267–277
Dinges DF (1995) Performance effects of fatigue. Fatigue Symposium Proceedings. National Transportation Safety Board, Washington (DC)
Dominguez C (1998) Expertise in laparoscopic surgery: anticipation and affordances. Naturalistic Decision Making 4. Warrenton (VA)
Dominguez C (1998) Expertise in laparoscopic surgery: anticipation and affordances. In: Proceedings of Naturalistic Decision Making 4. Warrenton, VA, USA
Dubois P, Rouland JF, Meseure P, Karpf S, Chaillou C (1995) Simulator for laser photocoagulation in ophthalmology. IEEE Trans Biomed Eng 42: 688–693
Eichhorn J (1989) Prevention of intraoperative anesthesia accidents and related severe injury through safety monitoring. Anesthesiology 70: 572–577
Flanagan JC (1954) The critical incident technique. Psychol Bull 59: 327–358
Gaba DM (1989) Human error in anesthetic mishaps. Int Anesthesiol Clin 27: 137–147
Gaba DM, Maxwell M, DeAnda A (1987) Anesthetic mishaps: breaking the chain of accident evolution. Anesthesiology 6: 670–676
Gawande AA, Thomas EJ, Zinner MJ, Brennan TA (1999) The incidence and nature of surgical adverse events in Colorado and Utah in 1992. Surgery 126: 66–75
Good ML, Gravenstein JS (1989) Anesthesia simulators and training devices. Int Anesthesiol Clin 27: 161–168
Herlitz J, Brandrup G, Haglid M, Karlson B, Albertsson P, Lurje L, Westberg S, Karlsson T (1997) Death, mode of death, morbidity, and rehospitalization after coronary artery bypass grafting in relation to occurrence of and time since a previous myocardial infarction. Thorac Cardiovasc Surg 45: 109–113
Howard SK, Gaba DM, Fish KJ, Yang G, Sarnquist FH (1992) Anesthesia crisis resource management training: teaching anesthesiologists to handle critical incidents. Aviat Space Environ Med 63: 763–770
Joice P, Hanna GB, Cuschieri A (1998) Errors enacted during endoscopic surgery—a human reliability analysis. Appl Ergon 29: 409–414
Katz P (1999) The scalpel’s edge: the culture of surgeons. Allwyn & Bacon. Boston, MA, USA
Leape LL (2000) Institute of medicine: medical error figures are not exaggerated. J Am Med Assoc 284: 95–97
Krizek T (2000) Surgical error: reflections on adverse events. Bull Am Coll Surg 85: 18–22
Kurz A, Sessler D, Lenhardt R (1996) Perioperative normthermia to reduce the incidence, of surgical wound infection and shorten hospitalization: study of wound infection and temperature group. New Engl J Med 334: 1209–1215
Leape L (1994) The preventability of medical injury. In: Bogner MS (ed) Human error in medicine. Lawrence Erlbaum, Hillsdale, NJ, USA. pp 13–25
Leape LL (2000) Institute of Medicine medical error figures are not exaggerated [comment]. JAMA 284: 95–97
Laird N, Lawthers AG, Localio AR, Barnes BA, Hebert L, Newhouse JP, Weiler PC, Hiatt H (1991) The nature of adverse events in hospitalized patients: results of the Harvard Medical Practice Study II. N Engl J Med 324: 377–384
Lunn J, Devlin B (1988) Lessons from the confidential enquiry into perioperative deaths in three NHS regions. Lancet 212: 1384–1386
McDonald CJ, Weiner M, Hui SL (2000) Deaths due to medical errors are exaggerated in Institute of Medicine report [comment]. JAMA 28: 93–96
Mackenzie C, Jefferies N, Hunter W, Bernard W, Xiao Y, Group TL, Horst R (1996) Comparison of self-reporting of deficiences in airway management with video analyses of actual performance. Human Factors 38: 623–635
Murphy S (2000) Deaths: final data for 1998. http://www.cdc.gov/ nchs/data/nvs48_11.pdf
National Transporation Safety Board. (2000) Accidents, fatalities, and rates, 1982 through 1999, for US air carriers operating under 14 CFR 121, scheduled and nonscheduled service (airlines) www.ntsb.gov/aviation/table5.htm
Pate-Cornell ME, Lakats LM, Murphy DM, Gaba DM (1997) Anesthesia patient risk: a quantitative approach to organizational factors and risk management options. Risk Anal 17: 511–523
Phillips O, Capizzi L (1974) Anesthesia mortality, Clin Anesth 10: 220–244
Reason J (1995) Understanding adverse events: human factors. Qual Health Care 4: 80–89
Reason JT (1990) Human error. Cambridge University Press, New York, p 302
Stark E, Oestreich K, Wendl K, Rumstadt B, Hagmuller E (1999) Nerve irritation after laparoscopic hernia repair. Surg Endosc 13: 878–881
Tendick F, Downes M, Cavusoglu MC, Gantert W, Way LW (1998) Development of virtual environments for training skills and reducing errors in laparoscopic surgery. Proceedings of the SPIE (International Society for Optical Engineering). International on Biological Optics (BIOS 98) San Jose, CA, USA. pp 36–44
Thomas EJ, Studdert DM, Burstin HR, Orav EJ, Zeena T, Williams EJ (1999) Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care 38: 261–271
Torsvall L, Akerstedt T (1988) Disturbed sleep while being oncall: an EEG study of ships’ engineers. Sleep 11: 35–38
Wanzel K, Jamieson C, Bohnen J (1999) Complications on a general surgery service: incidence and reporting. Can J Surg 43: 113–117
Wiener E, Kanki B, Helmreich R (1993) Cockpit resource management. Academic Press, San Diego (CA) p 519
Wilkinson R, Edwards R, Haines E (1996) Performance following a night of reduced sleep. Psychonom Sci X: 471–472
Z’Graggen K, Wehrli H, Metzger A, Buehler M, Frei E, Klaiber C (1998) Complications of laparoscopic cholecystectomy in Switzerland: a prospective 3-year study of 10,174 patients. Swiss Association of Laparoscopic and Thoracoscopic Surgery [comments]. Surg Endosc 12: 1303–1310
Author information
Authors and Affiliations
Additional information
Online publication: 14 May 2002
Rights and permissions
About this article
Cite this article
Calland, J.F., Guerlain, S., Adams, R.B. et al. A systems approach to surgical safety. Surg Endosc 16, 1005–1014 (2002). https://doi.org/10.1007/s00464-002-8509-3
Received:
Accepted:
Issue Date:
DOI: https://doi.org/10.1007/s00464-002-8509-3