The Big PictureAddressing human errors
Section snippets
Background
The risk of death from a medical error is substantial, with up to 90,000 deaths associated with medical errors occurring in the United States each year and the risk in the United Kingdom at nearly 1 death per day. Surgeons operate in an especially high-risk environment because more harm is caused in the operating room than in any other hospital area. Factors that contribute include staffing limits, high rates of staff turnover, and the type of operation. Among the causes of human error are
Personal Causes of Error
Tiredness and fatigue, poor nutrition and hydration, stress and emotional influences, and the need for multitasking with resultant situational disconnection are the main factors at a personal level that can lead to human error.
To counteract the effects of tiredness and fatigue, strict guidelines are in place in aviation that limit how many hours a crew can work. Such guidelines are less clear cut in medical settings, but the influences of being fatigued are well recognized, affecting
Team Responsibilities
In addition to their role in the operating room, the team should undergo an initial briefing and subsequent debriefing to identify problem areas, foster team function, and increase the sense of value in belonging to the team. The team leader should present the plan and confirm that there is shared understanding. Team members are responsible for monitoring each other for signs of loss of awareness or focus or developing fatigue. In addition, an open, “no-blame” culture and sense of equality as
References (0)
Cited by (0)
Brennan PA, Mitchell DA, Holmes S, et al: Good people who try their best can have problems: Recognition of human factors and how to minimise error. Br J Oral Maxillofac Surg 54:3-7, 2016
Reprints available from PA Brennan, Maxillofacial Unit, Portsmouth Hospitals NHS Trust, Portsmouth, PO6 3LY, UK: fax: +44 2392 286089; e-mail: [email protected]