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How crises work: A model of error cause and effect in surgical practice

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Petrut Gogalniceanu, Nikolaos Karydis, Nicos Kessaris, Jonathon Olsburgh, Francis Calder, Nick Sevdalis, Nizam Mamode

Original languageEnglish
Article number106711
JournalInternational Journal of Surgery
Volume104
DOIs
PublishedAug 2022

Bibliographical note

Funding Information: Nick Sevdalis' research is supported by the National Institute for Health Research (NIHR) Applied Research Collaboration (ARC) South London at King's College Hospital NHS Foundation Trust. NS is a member of King's Improvement Science, which offers co-funding to the NIHR ARC South London and comprises a specialist team of improvement scientists and senior researchers based at King's College London. Its work is funded by King's Health Partners (Guy's and St Thomas' NHS Foundation Trust, King's College Hospital NHS Foundation Trust, King's College London and South London and Maudsley NHS Foundation Trust), Guy's and St Thomas' Charity and the Maudsley Charity. Nick Sevdalis' research is further supported by the ASPIRES research programme (Antibiotic use across Surgical Pathways - Investigating, Redesigning and Evaluating Systems), funded by the Economic and Social Research Council. Nick Sevdalis is further funded by the National Institute of Health Research (NIHR) Global Health Research Unit on Health System Strengthening in Sub-Saharan Africa, King's College London (GHRU 16/136/54) using UK aid from the UK Government to support global health research. The views expressed in this publication are those of the author(s) and not necessarily those of the NIHR, the ESRC or the Department of Health and Social Care. Nizam Mamode reports consultancy funding from Novartis, Hansa, Takeda and Shire. He also reports grants from Hansa. These were all for activities outside the remit of this work. Petrut Gogalniceanu, Nikolaos Karydis, Nicos Kessaris, Jonathon Olsburgh and Francis Calder report no funding. Funding Information: Nick Sevdalis' research is supported by the National Institute for Health Research (NIHR) Applied Research Collaboration (ARC) South London at King's College Hospital NHS Foundation Trust . NS is a member of King's Improvement Science, which offers co-funding to the NIHR ARC South London and comprises a specialist team of improvement scientists and senior researchers based at King's College London. Its work is funded by King's Health Partners ( Guy's and St Thomas' NHS Foundation Trust , King's College Hospital NHS Foundation Trust , King's College London and South London and Maudsley NHS Foundation Trust ), Guy's and St Thomas' Charity and the Maudsley Charity. Nick Sevdalis' research is further supported by the ASPIRES research programme (Antibiotic use across Surgical Pathways - Investigating, Redesigning and Evaluating Systems), funded by the Economic and Social Research Council . Nick Sevdalis is further funded by the National Institute of Health Research (NIHR) Global Health Research Unit on Health System Strengthening in Sub-Saharan Africa, King's College London ( GHRU 16/136/54 ) using UK aid from the UK Government to support global health research. The views expressed in this publication are those of the author(s) and not necessarily those of the NIHR, the ESRC or the Department of Health and Social Care. Nizam Mamode reports consultancy funding from Novartis, Hansa, Takeda and Shire. He also reports grants from Hansa. These were all for activities outside the remit of this work. Petrut Gogalniceanu , Nikolaos Karydis , Nicos Kessaris, Jonathon Olsburgh and Francis Calder report no funding. Publisher Copyright: © 2022

King's Authors

Abstract

Introduction: Surgical crises have major consequences for patients, staff and healthcare institutions. Nevertheless, their aetiology and evolution are poorly understood outside the remit of root-cause analyses. Aims: To develop a crisis model in surgery in order to aid the reporting and management of safety critical events. Methods: A narrative review surveyed the safety literature on failure causes, mechanisms and effects in the context of surgical crises. Sources were identified using non-probability sampling, with selection and inclusion being determined by author panel consensus. The data underwent thematic analysis and reporting followed the recommendation of the SALSA framework. Results: Data from 133 sources derived five principal themes. Analysis suggested that surgical care processes become destabilized in a step-wise manner. This crisis chain is initiated by four categories of threat or risk: (i) the systems in which surgeons operate; (ii) surgeons' technical, cognitive and behavioural skills; (iii) surgeons’ physiological and psychological state (operational condition); and (iv) professional culture. Once triggered, the crisis chain is driven by only three types of errors: Type I. Performance errors consist of failures to diagnose, plan or execute tasks; Type II. Awareness errors are failures to recognise, comprehend or extrapolate the impact of performance failures; Type III. Rescue errors represent failures to correct faulty performance. The co-occurrence of all three error types gives rise to harm, which can lead to a crisis in the absence of mitigating actions. Conclusion: Surgical crises may be triggered by four categories of threat and driven by only three types of error. These may represent universal targets for safety interventions that create new opportunities for crisis management.

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