Researchers collected data from three adult teaching hospitals over six months. The hospitals performed over 5,300 surgeries during this period, 188 of which resulted in adverse events, including death and major complications. Of the 188 adverse events, over 50 percent, or 106, were due to human error.
The researchers also organized the errors by type. They were surprised to find that errors related to communication, teamwork and systems were relatively low. In contrast, over half of the errors were cognitive, involving lack of attention, lack of recognition and cognitive bias.
“This means our efforts to optimize communication, teamwork and system-related safety in our work culture have succeeded,” said James Suliburk, MD, associate professor of surgery at Baylor College of Medicine in Houston and the study’s first author.
To further decrease preventable medical errors, the study suggests, healthcare organizations should shift their focus to cognitive training and teach medical staff to recognize their own mental pitfalls.
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