Surgery
Volume 151, Issue 2 , Pages 139-145 , February 2012

Error training: Missing link in surgical education

  • Debra A. DaRosa, PhD

      Affiliations

    • Corresponding Author InformationReprint requests: Debra A. DaRosa, PhD, Department of Surgery, Northwestern University Feinberg School of Medicine, 251 E. Huron, Galter 3-150, Chicago, IL 60611.
  • ,
  • Carla M. Pugh, MD, PhD

,Accepted 4 August 2011.

References 

  1. Reason J. The human factor in medical accidents. In:  Vincent C,  Ennis M,  Audley RJ editor. Medical accidents. Oxford: Oxford University Press; 1993;p. 1–16
  2. Satava RM. The future of sugical simulation and surgical robotics. Bull Am Coll Surg. 2007;92:13–19
  3. Tang B, Hanna GB, Cuschieri A. Analysis of errors enacted by surgical trainees during skills training courses. Surgery. 2005;138:14–20
  4. In:  Kohn LT,  Corrigan JM,  Donaldson MS editor. To err is human: building a safer health system. Washington, DC: Institute of Medicine National Academies Press; 2000;
  5. Battles JB, Shea CE. A system of analyzing medical errors to improve GME curricula and programs. Acad Med. 2001;76:125–133
  6. Fabri PJ, Zayas-Castro JL. Human error, not communication and systems, underlies surgical complications. Surgery. 2008;144:557–565
  7. Singh H, Thomas EJ, Petersen LA, Studdert DM. Medical errors involving trainees: a study of closed malpractice claims from 5 insurers. Arch Intern Med. 2007;167:2030–2036
  8. Wu AW, Folkman S, McPhee SJ, Lo B. Do house officers learn from their mistakes?. JAMA. 1991;265:2089–2094
  9. Jagsi R, Kitch BT, Weinstein DF, Campbell EG, Hutter M, Weissman JS. Residents report on adverse events and their causes. Arch Intern Med. 2005;165:2607–2613
  10. Lesar TS, Briceland LL, Delcoure K, Parmalee JC, Masta-Gornic V, Pohl H. Medication prescribing errors in a teaching hospital. JAMA. 1990;263:2329–2334
  11. Chou C. Studies of cockpit task managment errors. Int J Aviation Psychol. 1996;6:307–320
  12. Smith L, Folkard S. The Impact of shift work on personnel at a nuclear plant; an exploratory study. Work Stress. 1993;7:341–350
  13. Proceedings of the Conference on Education to Reduce the Risk of Surgical Errors. January 31 to February 1, 2005 Chicago, IL: American College of Surgeons; 2005;
  14. Bann S, Khan M, Datta V, Darzi A. Surgical skill is predicted by the ability to detect errors. Am J Surg. 2005;189:412–415
  15. Croskerry P, Wears RL, Binder LS. Setting the educational agenda and curriculum for error prevention in emergency medicine. Acad Emerg Med. 2000;7:1194–1200
  16. Surbone A, Rowe M, Gallagher TH. Confronting medical errors in oncology and disclosing them to cancer patients. J Clin Oncol. 2007;25:1463–1467
  17. Paxton JH, Rubinfeld IS. Medical errors education: a prospective study of a new educational tool. Am J Med Qual. 2010;25:135–142
  18. Gordon L. Journey into the zen of M and M. Residency Assist Page. Available from: http://www.facs.org/education/rap/gordon0511.html. Accessed August 22, 2011.
  19. Bilimoria KY, Kmiecik TE, DaRosa DA, Halverson A, Eskandari MK, Bell RH, et al. Development of an online morbidity, mortality, and near-miss reporting system to identify patterns of adverse events in surgical patients. Arch Surg. 2009;144:305–311
  20. Dormann T, Frese M. Error training: replication and the function of exploratory behavior. Int J Hum Comput Interact. 1994;6:365–372
  21. Skinner BF. The technology of teaching. New York: Appleton-Century-Crofts; 1968;
  22. Frese M, Albrecht K, Altmann A, Lang J, Papstein P, Peryerl R, et al. The effects of an active development of the mental model in the training process: experimental results on a word processing system. Behav Inf Technol. 1988;7:295–304
  23. Ivancic K. Making the best of errors during training. Training Research Journal. 1995;1:103–125
  24. Keith N, Frese M. Effectiveness of error management training: a meta-analysis. J Appl Psychol. 2008;93:59–69
  25. Ivancic K, Hesketh B. Learning from errors in a driving simulation: effects on driving skill and self-confidence. Ergonomics. 2000;43:1966–1984
  26. Gully SM, Payne SC, Kiechel Koles KL, Whiteman JA. The impact of error training and individual differences on training outcomes: an attribute-treatment interaction perspective. J Appl Psychol. 2002;87:143–155
  27. Brannick MT, Fabri PJ, Zayas-Castro J, Bryant RH. Evaluation of an error-reduction training program for surgical residents. Acad Med. 2009;84:1809–1814
  28. Bingener J, Boyd T, Van Sickle K, Jung I, Saha A, Winston J, et al. Randomized double-blinded trial investigating the impact of a curriculum focused on error recognition on laparoscopic suturing training. Am J Surg. 2008;195:179–182
  29. Bann S, Datta V, Khan M, Darzi A. The surgical error examination is a novel method for objective technical knowledge assessment. Am J Surg. 2003;185:507–511
  30. Pugh C, Plachta S, Auyang E, Pryor A, Hungness E. Outcome measures for surgical simulators: is the focus on technical skills the best approach?. Surgery. 2010;147:646–654
  31. Tsuda S, Scott D, Doyle J, Jones DB. Surgical skills training and simulation. Curr Probl Surg. 2009;46:271–370
  32. Fried MP, Satava R, Weghorst S, Gallagher AG, Sasaki C, Ross D, et al. Identifying and reducing errors with surgical simulation. Qual Saf Health Care. 2004;13(Suppl 1):19–26
  33. Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med. 2003;78:775–780
  34. Rasmussen J. Human errors. A taxonomy for describing human malfunction in industrial installations. Journal of Occupational Accidents. 1982;4:311–333
  35. Croskerry P. The cognitive imperative: thinking about how we think. Acad Emerg Med. 2000;7:1223–1231
  36. Cuschieri A. Nature of human error: implications for surgical practice. Ann Surg. 2006;244:642–648
  37. Ioannidis JP, Lau J. Evidence on interventions to reduce medical errors: an overview and recommendations for future research. J Gen Intern Med. 2001;16:325–334
  38. Clarke JR. The quest for procedural safety: a suggested framework for the clinical study of operator-based technical errors during surgical procedures. Am J Surg. 2007;193:657–659
  39. Green R. The psychology of human error. Eur J Anaesthesiol. 1999;16:148–155
  40. Rogers SO, Gawande AA, Kwaan M, Puopolo AL, Yoon C, Brennan TA, et al. Analysis of surgical errors in closed malpractice claims at 4 liability insurers. Surgery. 2006;140:25–33
  41. Moulton CA, Regehr G, Mylopoulos M, MacRae HM. Slowing down when you should: a new model of expert judgment. Acad Med. 2007;82(10 Suppl):S109–S116
  42. Leape LL. A systems analysis approach to medical error. J Eval Clin Pract. 1997;3:213–222
  43. Redelmeier DA. Improving patient care. The cognitive psychology of missed diagnoses. Ann Intern Med. 2005;142:115–120
  44. Hall JC, Ellis C, Hamdorf J. Surgeons and cognitive processes. Br J Surg. 2003;90:10–16
  45. Lester H, Tritter JQ. Medical error: a discussion of the medical construction of error and suggestions for reforms of medical education to decrease error. Med Educ. 2001;35:855–861
  46. Engel KG, Rosenthal M, Sutcliffe KM. Residents’ responses to medical error: coping, learning, and change. Acad Med. 2006;81:86–93
  47. Hobgood C, Hevia A, Tamayo-Sarver JH, Weiner B, Riviello R. The influence of the causes and contexts of medical errors on emergency medicine residents’ responses to their errors: an exploration. Acad Med. 2005;80:758–764
  48. Leape LL, Berwick DM. Five years after To Err Is Human: what have we learned?. JAMA. 2005;293:2384–2390
  49. Flin R, Youngson G, Yule S. How do surgeons make intraoperative decisions?. Qual Saf Health Care. 2007;16:235–239

 Supported by the US Army Medical Research and Material Command (grant W81XWH0710190).

PII: S0039-6060(11)00474-0

doi: 10.1016/j.surg.2011.08.008

Surgery
Volume 151, Issue 2 , Pages 139-145 , February 2012