Dynamic modelling in a study of surgical error management

Solis-Trapala, Ivonne; Carthey, Jane; Farewell, Vernon T.; Leval, Marc R. de

doi:10.1002/sim.2886

Cited by 21 publications

(9 citation statements)

References 31 publications

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“…The correlation between non-error events and errors within trauma resuscitation is similar to findings in a study of errors occurring during cardiac surgery. (25)…”

Section: Discussionmentioning

confidence: 99%

Classification and team response to nonroutine events occurring during pediatric trauma resuscitation

Webman

Fritzeen

Yang

et al. 2016

Journal of Trauma and Acute Care Surgery

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Background Errors directly causing serious harm are rare during pediatric trauma resuscitation, limiting the use of adverse outcome analysis for performance improvement in this setting. Errors not causing harm due to mitigation or chance may have similar causation and are more frequent than those causing adverse outcomes. Analyzing these error types is an alternative to adverse outcome analysis. The purpose of this study was to identify errors of any type during pediatric trauma resuscitation and evaluate team responses to their occurrence. Methods Errors identified using video analysis were classified as errors of omission or commission, and selection errors using input from trauma experts. The responses to error types and error frequency based on patient and event features were compared. Results Thirty-nine resuscitations were reviewed, identifying 337 errors (range 2–26 per resuscitation). The most common errors were related to cervical spine stabilization (n=93, 27.6%). Errors of omission (n=135) and commission (n=106) were more common than errors of selection (n=96). Although 35.9% of all errors were acknowledged and compensation occurred after 43.6%, no response (acknowledgement or compensation) was observed after 51.3% of errors. Errors of omission and commission were more often acknowledged (40.7% and 39.6% vs. 25.0%, p=0.03 and p=0.04, respectively) and compensated for (50.4% and 47.2% vs. 29.2%, p=0.004 and p=0.01, respectively) than selection errors. Response differences between errors of omission and commission were not observed. The number of errors and the number of high-risk errors that occurred did not differ based on patient or event features. Conclusions Errors are common during pediatric trauma resuscitation. Teams did not respond to most errors, although differences in team response were observed between error types. Determining causation of errors may be an approach for identifying latent safety threats contributing to adverse outcomes during pediatric trauma resuscitation. LEVEL OF EVIDENCE VI STUDY TYPE prognostic

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“…The correlation between non-error events and errors within trauma resuscitation is similar to findings in a study of errors occurring during cardiac surgery. (25)…”

Section: Discussionmentioning

confidence: 99%

Classification and team response to nonroutine events occurring during pediatric trauma resuscitation

Webman

Fritzeen

Yang

et al. 2016

Journal of Trauma and Acute Care Surgery

View full text Add to dashboard Cite

show abstract

“…22 In one study, for every 3 minor problems above the mean of 9.9 per case, intraoperative performance was measurably reduced and operative duration increased. 23 The accumulation of minor disruptions and events apparently reduced the ability of the cardiac team to compensate for major errors 24 ; in short, "little things matter." 17,25 Surgical team members vary in their awareness of their own and their colleagues' teamwork skills.…”

mentioning

confidence: 99%

Patient Safety in the Cardiac Operating Room: Human Factors and Teamwork

et al. 2013

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“…Finally, although flagging omissions has face validity as a surrogate outcome measure it has not been proven that there is a link between flagging omissions and patient outcomes. One might argue that like previous research which has shown that operating theatre teams can cope with a certain number of minor errors before performance deteriorates,29 30 that H@N teams are able to cope with a certain number of flagging omissions before performance is negatively affected. Further research is needed to explore this issue.…”

Section: Discussionmentioning

confidence: 87%