HUMAN ERRORS IN SURGERY
 THE PERFORMANCE OF SURGICAL
OPERATIONS to be the MOST complex
psychomotor activity that human beings are called upon
to ...
• Willie King, age 51 with a
history of diabetes, consented
to a have a below knee
amputation on his right foot.
Surgeons ...
WHAT IS HUMAN ERROR ?
 An error is the failure of a planned action to
be completed as intended (error of execution)
or th...
ONION MODEL OF SURGICAL SYSTEM
Situational
interruptionsEquipments
design
Distractions
Team factors
Dealing with
unexpected
events
confidencecommunication
Individual
factors
fatigueperformance
Mentally
sound
Task factors
InformationClear
protocols
Patient factors
Co morbidity
Disease
severity
Anatomic
variations
Why Do Events Happen?
Sometimes
multiple errors
line up to allow
a significant
event or injury
to occur
Sometimes an error...
TYPES OF ERRORS
Faulty execution of a task
Misdiagnosis leading to wrong rule
Due to incomplete or incorrect
knowledge
HOW TO LOOK THE ERRORS?
 Person approach- old type
- only doctor is responsible
- less chance of learning
 System approa...
 The complexity should be reduced.
 Procedures should be standardized as much
as possible.
 The information process sho...
HOW TO AVOID ERRORS ?
 Pay attention to detail- ST A R
 Proper communication
 Support each other • Stop
• Think
• Act
•...
TAKE HOME MESSAGE
 Human error is inevitable and unavoidable.
 The systems approach is required to
significantly reduce ...
‘‘Fallibility is part of the human condition;We
cant change the human condition, but we can
change the conditions under wh...
THANK YOU
Human errors in surgery by dr dinesh bhu
Human errors in surgery by dr dinesh bhu
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Human errors in surgery by dr dinesh bhu

  1. 1. HUMAN ERRORS IN SURGERY
  2. 2.  THE PERFORMANCE OF SURGICAL OPERATIONS to be the MOST complex psychomotor activity that human beings are called upon to perform.
  3. 3. • Willie King, age 51 with a history of diabetes, consented to a have a below knee amputation on his right foot. Surgeons amputated is left foot in error.
  4. 4. WHAT IS HUMAN ERROR ?  An error is the failure of a planned action to be completed as intended (error of execution) or the use of the wrong plan to achieve an aim (error of planning).  The 1999 Institute of Medicine Report suggested medical errors are the eighth leading cause of death in the United States, causing up to 100,000 deaths annually
  5. 5. ONION MODEL OF SURGICAL SYSTEM
  6. 6. Situational interruptionsEquipments design Distractions
  7. 7. Team factors Dealing with unexpected events confidencecommunication
  8. 8. Individual factors fatigueperformance Mentally sound
  9. 9. Task factors InformationClear protocols
  10. 10. Patient factors Co morbidity Disease severity Anatomic variations
  11. 11. Why Do Events Happen? Sometimes multiple errors line up to allow a significant event or injury to occur Sometimes an error occurs, but an event or injury is prevented by an internal system of checks Significant events or injuries From Managing the Risks of Organizational Accidents, James Reason
  12. 12. TYPES OF ERRORS Faulty execution of a task Misdiagnosis leading to wrong rule Due to incomplete or incorrect knowledge
  13. 13. HOW TO LOOK THE ERRORS?  Person approach- old type - only doctor is responsible - less chance of learning  System approach – - whole system is responsible - more chance correction
  14. 14.  The complexity should be reduced.  Procedures should be standardized as much as possible.  The information process should be optimized by using checklists and reminders.  Equipment and instruments should be improved and standardized.  Training should be adequate HOW TO AVOID ERRORS ?
  15. 15. HOW TO AVOID ERRORS ?  Pay attention to detail- ST A R  Proper communication  Support each other • Stop • Think • Act • Review
  16. 16. TAKE HOME MESSAGE  Human error is inevitable and unavoidable.  The systems approach is required to significantly reduce the number of human errors in surgery.  The blaming culture should be rejected.  System should be less complex and standardized.  Training should be adequate
  17. 17. ‘‘Fallibility is part of the human condition;We cant change the human condition, but we can change the conditions under which people work.”
  18. 18. THANK YOU

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