Mushtaq, F orcid.org/0000-0001-7881-1127, O’Driscoll, C, Smith, FCT et al. (3 more authors) (2018) Contributory factors in surgical incidents as delineated by a confidential reporting system. Annals of the Royal College of Surgeons of England, 100 (5). pp. 401-405. ISSN 0035-8843
Abstract
Background
Confidential reporting systems play a key role in capturing information about adverse surgical events. However, the value of these systems is limited if the reports that are generated are not subjected to systematic analysis. The aim of this study was to provide the first systematic analysis of data from a novel surgical confidential reporting system to delineate contributory factors in surgical incidents and document lessons that can be learned.
Methods
One-hundred and forty-five patient safety incidents submitted to the UK Confidential Reporting System for Surgery over a 10-year period were analysed using an adapted version of the empirically-grounded Yorkshire Contributory Factors Framework.
Results
The most common factors identified as contributing to reported surgical incidents were cognitive limitations (30.09%), communication failures (16.11%) and a lack of adherence to established policies and procedures (8.81%). The analysis also revealed that adverse events were only rarely related to an isolated, single factor (20.71%) – with the majority of cases involving multiple contributory factors (79.29% of all cases had more than one contributory factor). Examination of active failures – those closest in time and space to the adverse event – pointed to frequent coupling with latent, systems-related contributory factors.
Conclusions
Specific patterns of errors often underlie surgical adverse events and may therefore be amenable to targeted intervention, including particular forms of training. The findings in this paper confirm the view that surgical errors tend to be multi-factorial in nature, which also necessitates a multi-disciplinary and system-wide approach to bringing about improvements.
Metadata
Item Type: | Article |
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Authors/Creators: |
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Copyright, Publisher and Additional Information: | c) 2019, The Royal College of Surgeons of England. This is the published version of a paper published in The Annals of The Royal College of Surgeons of England. Uploaded in accordance with the publisher's self-archiving policy. |
Keywords: | Safety incidents, Adverse events, Contributory factors, Cognitive factors, Latent contributors |
Dates: |
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Institution: | The University of Leeds |
Academic Units: | The University of Leeds > Faculty of Medicine and Health (Leeds) > School of Psychology (Leeds) |
Depositing User: | Symplectic Publications |
Date Deposited: | 23 Feb 2018 11:47 |
Last Modified: | 07 Jun 2019 18:38 |
Status: | Published |
Publisher: | Royal College of Surgeons of England |
Identification Number: | 10.1308/rcsann.2018.0025 |
Open Archives Initiative ID (OAI ID): | oai:eprints.whiterose.ac.uk:127853 |