Introduction
We report the first prospective analysis of human factors elements contributing to
invasive procedural never events by using a validated Human Factors Analysis and Classification
System (HFACS).
Methods
From August 2009 to August 2014, operative and invasive procedural “Never Events”
(retained foreign object, wrong site/side procedure, wrong implant, wrong procedure)
underwent systematic causation analysis promptly after the event. Contributing human
factors were categorized using the 4 levels of error causation described by Reason
and 161 HFACS subcategories (nano-codes).
Results
During the study, approximately 1.5 million procedures were performed, during which
69 never events were identified. A total of 628 contributing human factors nano-codes
were identified. Action-based errors (n = 260) and preconditions to actions (n = 296) accounted for the majority of the nano-codes across all 4 types of events,
with individual cognitive factors contributing one half of the nano-codes. The most
common action nano-codes were confirmation bias (n = 36) and failed to understand (n = 36). The most common precondition nano-codes were channeled attention on a single
issue (n = 33) and inadequate communication (n = 30).
Conclusion
Targeting quality and interventions in system improvement addressing cognitive factors
and team resource management as well as perceptual biases may decrease errors and
further improve patient safety. These results delineate targets to further decrease
never events from our health care system.
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Article info
Publication history
Published online: May 29, 2015
Accepted:
March 12,
2015
Footnotes
Research reported in this manuscript was supported in part by the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health under award number K23DK93553. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Dr Hallbeck receives grant funding from Stryker Endoscopy. This funding is not perceived as constituting a conflict of interest for the accepted manuscript. Dr Bingener is supported through a research grant (NIDDK), specified research through Nestle and Stryker Endoscopy, has received travel support from Intuitive Surgical, and serves on the Surgeon Advisory Board for Titan Medical. She perceives no conflict of interest as it relates to the manuscript. Other than Dr Bingener's time, no financial support was provided for the preparation of the manuscript.
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© 2015 Elsevier Inc. Published by Elsevier Inc. All rights reserved.
