“HUMAN ERROR, NOT COMMUNICATION AND SYSTEMS, UNDERLIES SURGICAL COMPLICATIONS”: A FOLLOWUP CONVERSATION WITH PETER FABRI MD.

               In April 2015, while welcoming the membership of the Association of VA Surgeons to Virginia, Dr. LD Britt challenged surgeons in the VA to address the concerns regarding persistence of adverse events in medicine. Dr. Britt has agreed to elaborate on that topic. In the process of developing questions for him on this topic, one of my questions was whether these adverse events are due simply to providers or staff not doing what they were supposed to be doing or to poor system designs affiliated with poor communication processes. Dr. Peter J. Fabri, MD, PhD, FACS wrote a beautiful paper on this topic in 2008 so I solicited his opinion on this topic and he was gracious to call me on the phone.

In Peter Fabri’s 2008 review of 9830 patient procedures performed over 12 months, 332 major complications were encountered.  In 25% of cases the patient either died or suffered permanent injury. Dr. Fabri utilized a classification system that separated the errors into those attributed to human factors (sole provider or team), to system design errors, or to communication errors (see table below). They reported that 78.3% of their patient complications were related to a medical error and in75% of those cases the error contributed to over 50% of the outcome. In contrast to many other publications on this topic, system issues and communication issues combined contributed to only 4% of the complications. In cases with error, 63.5% were due to an ‘‘error of technique’’ (63.5%), 20% from a ‘‘mistake’’ (doing the wrong thing) and in 58% from a ‘‘slip’’ (doing the right thing incorrectly).  Errors in judgment were reported in 29.6%, inattention to detail in 29.3%, and incomplete understanding of the problem in 22.7%. The study contradicts the conclusions made in other studies where those studies indicate that system reengineering and Crew Resource Management / team training / communication training should solve most of our problems. Dr. Fabri offered an explanation as to why their study differs from others in that their study assesses ALL complications and not simply Sentinel Events.  They concede that the majority of sentinel events are likely to be a factor of system or communication error rather than an error produced by one individual (and no sentinel events occurred in their series).

 

CLASSIFICATION SYSTEM OF ERRORS
ERROR TYPE	%
Equipment failure/ mechanical Error	7.7
Health System/ organizational Error	5.4
Communication Error	5.8
Incomplete understanding of the problem	22.7
Failure to use established protocol	5.4
Carelessness/inattention to detail	29.2
Error in Diagnosis	12.3
Judgment Error	29.6
Delay Error	10.8
Error of Omission	1.5
Technique Error	63.5
(In many cases more than one type could be attributed to the result)

 

MY QUESTION TO DR. FABRI WAS- AFTER 8 YEARS DO YOU BELIEVE THAT HUMAN FACTOR ERROR IS STILL THE PREVALENT CAUSE OF SURGICAL COMPLICATIONS?

Yes absolutely I believe this is true- Surgeons make mistakes because we are ignorant!


Much of this has to do with how we are trained.  I commonly hear “when I was a resident” which of course means “that is how we did it and there is no other way”. We cease training the last day of residency. We then use the if-then methodology. But that is not how life is in reality.


While some events are deterministic (this is for certain, ‘always’), some are probabilistic (we know the potential chance that it will occur), most are stochastic (subject to chance). Unfortunately


Medicine is taught as a deterministic science but in reality it is NOT deterministic but is stochastic. There are many options for many different scenarios and virtually nothing is 100% certain.


Since my PhD in Industrial engineering, I understand the whole field of human error much better now.


You must realize that errors occur in either two ways: mistakes (occur during learning and are amenable to training) or Slips (which occur in the experienced person when they are not focused or distracted).


The only complications that occur in medicine that are truly due to systems’ problems are sentinel events and those are the ones that hit the paper. In our paper, none of the complications were sentinel events. For every sentinel event there are thousands of non-sentinel events. These occur because we are not paying attention.

Surgeons are not bad people, but if they are lazy or ignorant it is because they were not trained to understand how these slips and mistakes happen.

Another thing to consider is risk taking: If we have a positive attitude towards the situation we minimize the risk and if we have a negative attitude we exaggerate the risk (this reminded me of my conversation with Dr. Moulton on this topic in December).

 

WHAT POSITIVE ACTION HAS RESULTED FROM THIS UNDERSTANDING - HOW HAS THIS HELPED YOU IN TRAINING STUDENTS, RESIDENTS, FACULTY?

Well you remember that surgery has been run as an 'iron fist'. We would publically humiliate you if you made a mistake. I changed M&M to the SBAR approach. We assess that “Ok, this happened. I don’t want to know why it happened, but how can we prevent this from happening again.” We quickly saw a reduction in mortality based on these lessons learned.

 

KENNETH A. LIPSHY, MD, FACS

www.crisismanagementleadership.com

Peter J. Fabri, MD, PhD; Surgeon and PhD in Industrial Engineering at the University of South Florida; currently faculty in Colleges of Engineering and Medicine in the new hybrid discipline of "Health Systems Engineering".

 

Fabri PJ, Zayas-Castro JL. Human error, not communication and systems, underlies surgical complications. Surgery. 2008;144(4):557-565.