Analysis of Human Performance Deficiencies Associated with Surgical Adverse Events

Suliburk JW, Buck QM, Pirko CJ, Massarweh NN, Barshes NR, Singh H, Rosengart TK. JAMA Netw Open. 2019 Jul 3;2(7):e198067. [CrossRef] [PubMed]

Potentially preventable adverse events remain a formidable cause of patient harm and health care expenditure despite advances in systems-based risk-reduction strategies. The authors analyzed the incidence of human performance deficiencies (HPDs) during the provision of surgical care using 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.

A total of 188 adverse events were recorded, including 182 adverse events (96.8%) among 5365 patients who underwent surgical operations and 6 adverse events (3.2%) among patients undergoing nonoperative treatment. Among these 188 adverse events, 106 (56.4%) were associated with HPDs. Among these 106 HPD adverse events over half were attributed to human performance deficiencies in execution, planning or problem solving, communication, teamwork, and rules violation. Among the adverse events listed in Table 1 of the article were surgical site infection and wound dehiscence (12.2%); unexpected bleeding or transfusion (8%); deep venous thrombosis and pulmonary embolism (6.4%); unplanned intubation, pneumonia, and the patient needing a ventilator more than 48 hours after the operation has ended (5.9%), sepsis or septic shock (4.3%).

The authors conclude that human performance deficiencies were identified in more than half of adverse events, most commonly associated with cognitive error in the execution of care. It is unclear how many of these adverse events relate to human performance deficiencies including cognitive error.