Surgical never events and contributing human factors.

ABSTRACT:

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 id

SUBMITTER: Thiels CA 

PROVIDER: S-EPMC4492832 | biostudies-literature | 2015 Aug

REPOSITORIES: biostudies-literature