J Neurosurg. 2014 Aug;121(2):297-304. doi: 10.3171/2014.5.JNS132341. Epub 2014 Jun 13.
OBJECT: Error recording and monitoring is an important component of error prevention and quality assurance in the health sector given the huge impact of medical errors on the well-being of patients and the financial loss incurred by health institutions. With this in mind, assessing the effect of reporting errors should be a cause worth pursuing. The object in this study was to examine the null hypothesis that recording and publishing errors do not affect error patterns in a clinical practice. METHODS: Intraoperative errors and their characteristics were prospectively recorded between May 2000 and May 2013 in the neurosurgical practice of the senior author (M.B.). The error pattern observed between May 2000 and August 2006, which has been previously described (Group A), was compared with the error pattern observed between September 2006 and May 2013 (Group B). RESULTS: A total of 1108 cases in Group A and 974 cases in Group B were surgically treated. A total of 2684 errors were recorded in Group A, while 1892 errors were recorded in Group B. The ratios of cranial to spinal procedures performed in Groups A and B were 3:1 and 10:1, respectively, while the ratios of general to local anesthesia in the two groups were 2:1 and 1.3:1, respectively (p < 0.0001 for both). There was a significantly decreased proportion of cases with error (87% to 83%, p < 0.006), mean errors per case (2.4 to 1.9, p < 0.0001), proportion of error-related complications (16.7% to 5.5%, p < 0.002), and clinical impacts of error (2.7% to 1.0%, p < 0.0001) in Group B compared with Group A. Errors in Group B tended to be more preventable than those in Group A (85.8% vs 78.5%, p < 0.0001). A significant reduction was also noticed with most types of error. A descending trend in the mean errors per case was demonstrated from the years 2001 to 2012; however, an increased severity of errors (22.6% to 29.5%, p < 0.0001) was recorded in Group B compared with Group A. CONCLUSIONS: Data in this study showed that the act of recording errors might alter behaviors, resulting in fewer errors.
KEYWORDS: ASA = American Society of Anesthesiologists; error recording; intraoperative error; neurosurgery; prospective study
BACKGROUND: Cognitive errors are thought-process errors, or thinking mistakes, which lead to incorrect diagnoses, treatments, or both. This psychology of decision-making has received little formal attention in anaesthesiology literature, although it is widely appreciated in other safety cultures, such as aviation, and other medical specialities. We sought to identify which types of cognitive errors are most important in anaesthesiology. METHODS: This study consisted of two parts. First, we created a cognitive error catalogue specific to anaesthesiology practice using a literaturereview, modified Delphi method with experts, and a survey of academic faculty. In the second part, we observed for those cognitive errors during resident physician management of simulated anaesthesiology emergencies. RESULTS: Of >30 described cognitive errors, the modified Delphi method yielded 14 key items experts felt were most important and prevalent in anaesthesiology practice (Table 1). Faculty survey responses narrowed this to a 'top 10' catalogue consisting of anchoring, availability bias, premature closure, feedback bias, framing effect, confirmation bias, omission bias, commission bias, overconfidence, and sunk costs (Table 2). Nine types of cognitive errors were selected for observation during simulated emergency management. Seven of those nine types of cognitive errorsoccurred in >50% of observed emergencies (Table 3). CONCLUSIONS: Cognitive errors are thought to contribute significantly to medical mishaps. We identified cognitive errors specific to anaesthesiology practice. Understanding the key types of cognitive errors specific to anaesthesiology is the first step towards training in metacognition and de-biasing strategies, which may improve patient safety.
Ann Transl Med. 2015 May;3(8):111. doi: 10.3978/j.issn.2305-5839.2015.04.14.
The management of surgical and medical intraoperative emergencies are included in the group of high acuity (high potential severity of an event and the patient impact) and low opportunity (the frequency in which the team is required to manage the event). This combination places the patient into a situation where medical errors could happen more frequently. Although medical error are ubiquitous and inevitable we should try to establish the necessary knowledge, skills and attitudes needed for effective team performance and to guide the development of a critical event. This strategy would probably reduce the incidence of error and improve decision-making. The way to apply it comes from the application of the management of critical events in the airline industry. Its use in a surgical environment is through the crisis resource management (CRM) principles. The CRM tries to develop all the non-technical skills necessary in a critical situation, but not only that, also includes all the tools needed to prevent them. The purpose of this special issue is to appraise and summarize the design, implementation, and efficacy of simulation-based CRM training programs for a specific surgery such as the non-intubated video-assisted thoracoscopic surgery.
KEYWORDS: Crisis; anesthesia; intraoperative complications; thoracic surgery