Reducing OR Cognitive Workload May Address Human Factors That Lead to Adverse Events

July 15, 2015 | Strategic Insights for Health System


Targeting quality and systems improvement interventions to address cognitive factors, team resource management, and perceptual biases may decrease the rate of surgical adverse events and further improve patient safety, concludes a study published in the August 2015 issue of Surgery. Of approximately 1.5 million surgical procedures performed from 2009 to 2014 at a tertiary care hospital, researchers identified the occurrence of 69 "never events," including cases of wrong-site/side surgery, wrong procedure, wrong implant, and unintended retained foreign objects. Systematic causation analysis was conducted promptly after each of the events, and in total, more than half of the contributing human factors nanocodes generated were related to individual cognitive factors.

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