Human reliability analysis: a new method to quantify errors in cataract surgery

Cox, Andrew T.; Dolan, Lori A.; MacEwen, C J

doi:10.1038/sj.eye.6702648

Cited by 16 publications

(7 citation statements)

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“…Hazard zones and difficult tasks were identified in all major commonly performed laparoscopic operations such as general surgical, colorectal, bariatric and ENT operations [16,21,25,27,29,30,32,33]. Examples include dissection of triangle of Calot during LChole, dissection of right side of pelvis during laparoscopic resection of rectal cancer, mobilization of the greater curvature and stapling of the stomach during sleeve gastrectomy and access to nasal cavity during endoscopic dacryocystorhinostomy (DCR).…”

Section: Resultsmentioning

confidence: 99%

“…OCHRA assesses the quality of execution by a surgeon (performance level) by detection and characterisation of technical errors (procedural/execution) and (consequential/inconsequential) enacted by the operator during the operation [16,[21][22][23][24][25][26][27][28][29][30][31][32][33][34]. In this process OCHRA, divides the continuum of an operation into steps, tasks and hazard zones, the last referring to sections of an operation where major errors, some catastrophic, iatrogenic injuries, occur most commonly [16,21,[25][26][27][28][29][30][31][32][33].…”

Section: Discussionmentioning

confidence: 99%

“…Underling mechanisms which provide a deeper understanding of the likelihood of occurrence of technical errors were reported in some studies, e.g., applying excessive force, incorrect order of steps, concentration lapses, misjudgements, poor instrument selection etc., have been identified as factors. Several hazard zones have also been described (Table 1) [15,16,21,22,[25][26][27][28][29][30] and difficult tasks highlighted [27,34]. OCHRA enables differentiation between LCs and P-GCs.…”

Section: Discussionmentioning

confidence: 99%

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Objective assessment of surgical operative performance by observational clinical human reliability analysis (OCHRA): a systematic review

Tang

Cuschieri

2020

Surg Endosc

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Background Both morbidity and mortality data (MMD) and learning curves (LCs) do not provide information on the nature of intraoperative errors and their mechanisms when these adversely impact on patient outcome. OCHRA was developed specifically to address the unmet surgical need for an objective assessment technique of the quality of technical execution of operations at individual operator level. The aim of this systematic review was to review of OCHRA as a method of objective assessment of surgical operative performance. Methods Systematic review based on searching 4 databases for articles published from January 1998 to January 2019. The review complies with Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines and includes original publications on surgical task performance based on technical errors during operations across several surgical specialties. Results Only 26 published studies met the search criteria, indicating that the uptake of OCHRA during the study period has been low. In 31% of reported studies, the operations were performed by fully qualified consultant/attending surgeons and by surgical trainees in 69% in approved training programs. OCHRA identified 7869 consequential errors (CE) during the conduct of 719 clinical operations (mean = 11 CEs). It also identified 'hazard zones' of operations and proficiency-gain curves (P-GCs) that confirm attainment of persistent competent execution of specific operations by individual trainee surgeons. P-GCs are both surgeon and operation specific. Conclusions Increased OCHRA use has the potential to improve patient outcome after surgery, but this is a contingent progress towards automatic assessment of unedited videos of operations. The low uptake of OCHRA is attributed to its laborintensive nature involving human factors (cognitive engineering) expertise. Aside from faster and more objective peer-based assessment, this development should accelerate increased clinical uptake and use of the technique in both routine surgical practice and surgical training. Keywords Observational clinical human reliability analysis (OCHRA) • Objective assessment of surgical operative performance • Technical error • Task performance • Hazard zones of operations • Proficiency-gain curves

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Section: Resultsmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Objective assessment of surgical operative performance by observational clinical human reliability analysis (OCHRA): a systematic review

Tang

Cuschieri

2020

Surg Endosc

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“…In surgery, there has been progress toward analyzing errors rather than complications, which allows personnel to more accurately anticipate, avoid, and identify adverse events. 24 In an effort to prevent, mitigate, and identify errors, classifications of human error have been created to determine the underlying source(s) or root cause(s) that leads to errors. For instance, one categorization classifies errors as skill based (ie faulty execution of the task), rule based (ie misclassification or misdiagnosis leading to the action), or knowledge based (ie from incomplete or incorrect knowledge).…”

Section: Human Factors Of Surgerymentioning

confidence: 99%

Quality and Safety of Minimally Invasive Surgery: Past, Present, and Future

McCrory

LaGrange

Hallbeck

2014

Biomed Eng Comput Biol

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Adverse events because of medical errors are a leading cause of death in the United States (US) exceeding the mortality rates of motor vehicle accidents, breast cancer, and AIDS. Improvements can and should be made to reduce the rates of preventable surgical errors because they account for nearly half of all adverse events within hospitals. Although minimally invasive surgery (MIS) has proven patient benefits such as reduced postoperative pain and hospital stay, its operative environment imposes substantial physical and cognitive strain on the surgeon increasing the risk of error. To mitigate errors and protect patients, a multidisciplinary approach is needed to improve MIS. Clinical human factors, and biomedical engineering principles and methodologies can be used to develop and assess laparoscopic surgery instrumentation, practices, and procedures. First, the foundational understanding and the imperative to transform health care into a high-quality and safe system is discussed. Next, a generalized perspective is presented on the impact of the design and redesign of surgical technologies and processes on human performance. Finally, the future of this field and the research needed to further improve the quality and safety of MIS is discussed.

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“…Durch die Verwendung von präoperativen Bewertungssystemen zur Einstufung des Schwierigkeitsgrades einer Operation bzw. zur Auswahl eines/r geeigneten Chirurgen/in könnte die intraoperative Komplikationsrate gesenkt werden und geeignete Fälle für ChirurgInnen in Ausbildung gefunden werden [24][25][26]. Die Etablierung eines strukturierten Ausbildungsplanes mit Berücksichtigung der operativen Tätigkeiten an der Augenabteilung durch Erstellung von Arbeitsanweisungen und Checklisten für AssistenzärztInnen und das Führen von MitarbeiterInnenorientierungsgesprächen in Hinblick auf die Operationstätigkeit führte zu dieser klaren Reduktion der operativen Komplikationsrate, wie bereits andere Untersuchungen zeigen konnten [29].…”

Section: Hintergrundunclassified

Qualitäts-Statistik von Operationen an der Augenabteilung des Krankenhauses Hietzing in Wien

Weingessel

Vécsei

Irsigler

et al. 2011

Spektrum Augenheilkd.

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Background: Intraoperative complication rate as quality-criteria in cataract-surgery varies from 2.3 % to 27.4 % in literature. Re-surgery rate for vitreoretinal surgeries ranges from 1.1 % to 14 %. Some preoperative conditions and intraoperative factors have a serious impact on complication rate. Other affecting factors are the surgeon's expertness, the structure of the surgical curriculum and the intraoperative management. Material and Methods: A retrospective chart review of 17.665 surgeries, the number of cataract surgeries and vitreoretinal surgeries were recorded, data of re-surgeries due to complications were collected. Based on complication rates of the year 2007 and 2008 the following actions were taken: Identification of pre-and intraoperative risk factors, allocating complicated surgeries to experienced surgeons, consistent intraoperative management and a structured surgical curriculum. Results: Massive reduction of re-surgeries in both cataract and vitreoretinal surgery was achieved, 66.8 % for cataract surgery and 86.6 % for vitreoretinal surgery. Conclusions: Identifying pre-and intraoperative risk factors, allocating complicated surgeries to experienced surgeons, consistent intraoperative management and a structured surgical curriculum reduce intraoperative complications and re-surgery rate dramatically. Zusammenfassung. Hintergrund: Die Komplikationsraten als Kriterium für die Qualität bei Katarakt-Operationen variieren in der Literatur zwischen 2,3 % bis 27,4 %. Die Re-Operationsraten bei vitreoretinalen Operationen liegen zwischen 1,1 % und 14 %. Es gibt verschiedene prä-und intraoperative Faktoren, die einen Einfluss auf die Komplikationsrate haben. Aber auch die Erfahrenheit der ChirurgIn und die Strukturiertheit der Ausbildung haben Auswirkungen, ebenso wie das intraoperative Management. Material und Methode: Retrospektive Untersuchung aller Operationen, die zwischen Jänner 2007 und März 2011 an der Augenabteilung durchgeführt wurden, mit Schwerpunkt auf Katarakt-und vitreoretinale Operationen. Basierend auf den Kom pli kationsraten von 2007 und 2008 kamen folgende Maß-nahmen zur Anwendung: präoperative Identifikation von prä-und intraoperativen Risikofaktoren, die Auswahl einer/s geeigneten Operateur/in, konsequentes intraoperatives Kompli kationsmanagement und ein strukturierter Ausbildungsplan für AssistenzärztInnen. Resultate: Reduktion der Re-Operationsrate bei Katarakt-Operationen um 66,8 % seit 2007 bzw. um 64,8 % seit 2008 und der Re-Operationsrate von vitreoretinalen Operationen um 86,6 % im Vergleich zu 2007 bzw. 59,3 % zu 2008. Schlussfolgerung: Die Berücksichtigung von prä-und intraoperativen Risikofaktoren, die Auswahl einer/s geeigneten Operateur/in, konsequentes intraoperatives Komplikationsmanagement und ein strukturierter Ausbildungsplan für AssistenzärztInnen führt zu einer wesentlichen Reduktion von OP-Komplikationen und Re-Operationen.

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Human reliability analysis: a new method to quantify errors in cataract surgery

Cited by 16 publications

References 2 publications

Objective assessment of surgical operative performance by observational clinical human reliability analysis (OCHRA): a systematic review

Objective assessment of surgical operative performance by observational clinical human reliability analysis (OCHRA): a systematic review

Quality and Safety of Minimally Invasive Surgery: Past, Present, and Future

Qualitäts-Statistik von Operationen an der Augenabteilung des Krankenhauses Hietzing in Wien

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