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Contributory factors in surgical incidents as delineated by a confidential reporting system

Mushtaq, F; O'Driscoll, C; Smith, F; Wilkins, D; Kapur, N; Lawton, R; (2018) Contributory factors in surgical incidents as delineated by a confidential reporting system. Annals of The Royal College of Surgeons of England , 100 (5) pp. 410-405. 10.1308/rcsann.2018.0025. Green open access

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Abstract

Background: Confidential reporting systems play a key role in capturing information about adverse surgical events. However, the value of these systems is limited if the reports that are generated are not subjected to systematic analysis. The aim of this study was to provide the first systematic analysis of data from a novel surgical confidential reporting system to delineate contributory factors in surgical incidents and document lessons that can be learned. / Methods: One-hundred and forty-five patient safety incidents submitted to the UK Confidential Reporting System for Surgery over a 10-year period were analysed using an adapted version of the empirically-grounded Yorkshire Contributory Factors Framework. / Results: The most common factors identified as contributing to reported surgical incidents were cognitive limitations (30.09%), communication failures (16.11%) and a lack of adherence to established policies and procedures (8.81%). The analysis also revealed that adverse events were only rarely related to an isolated, single factor (20.71%) – with the majority of cases involving multiple contributory factors (79.29% of all cases had more than one contributory factor). Examination of active failures – those closest in time and space to the adverse event – pointed to frequent coupling with latent, systems-related contributory factors. / Conclusions: Specific patterns of errors often underlie surgical adverse events and may therefore be amenable to targeted intervention, including particular forms of training. The findings in this paper confirm the view that surgical errors tend to be multi-factorial in nature, which also necessitates a multi-disciplinary and system-wide approach to bringing about improvements.

Type: Article
Title: Contributory factors in surgical incidents as delineated by a confidential reporting system
Location: England
Open access status: An open access version is available from UCL Discovery
DOI: 10.1308/rcsann.2018.0025
Publisher version: https://doi.org/10.1308/rcsann.2018.0025
Language: English
Additional information: This version is the author accepted manuscript. For information on re-use, please refer to the publisher’s terms and conditions.
Keywords: Adverse events, Cognitive factors, Contributory factors, Latent contributors, Safety incidents
UCL classification: UCL
UCL > Provost and Vice Provost Offices > School of Life and Medical Sciences
UCL > Provost and Vice Provost Offices > School of Life and Medical Sciences > Faculty of Brain Sciences
UCL > Provost and Vice Provost Offices > School of Life and Medical Sciences > Faculty of Brain Sciences > Div of Psychology and Lang Sciences
UCL > Provost and Vice Provost Offices > School of Life and Medical Sciences > Faculty of Brain Sciences > Div of Psychology and Lang Sciences > Clinical, Edu and Hlth Psychology
URI: https://discovery.ucl.ac.uk/id/eprint/10045463
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