Importance: Potentially preventable adverse events remain a formidable cause of patient harm and health care expenditure despite advances in systems-based risk-reduction strategies.
Objective: To analyze and describe the incidence of human performance deficiencies (HPDs) during the provision of surgical care to identify opportunities to enhance patient safety.
Design, Setting, And Participants: This quality improvement study used a new taxonomy to inform the development and implementation of an HPD classifier tool to categorize HPDs into errors associated with cognitive, technical, and team dynamic functions. The HPD classifier tool was then used to concurrently analyze surgical adverse events in 3 adult hospital affiliates-a level I municipal trauma center, a quaternary care university hospital, and a US Veterans Administration hospital-from January 2, 2018, to June 30, 2018. Surgical trainees presented data describing all adverse events associated with surgical services at weekly hospital-based morbidity and mortality conferences. Adverse events and HPDs were classified in discussion with attending faculty and residents. Data were analyzed from July 9, 2018, to December 23, 2018.
Main Outcomes And Measures: The incidence and primary and secondary causes of HPDs were classified using an HPD classifier tool.
Results: A total of 188 adverse events were recorded, including 182 adverse events (96.8%) among 5365 patients who underwent surgical operations and 6 adverse events (3.2%) among patients undergoing nonoperative treatment. Among these 188 adverse events, 106 (56.4%) were associated with HPDs. Among these 106 HPD adverse events, a total of 192 HPDs (mean [SD], 1.8 [0.9] HPDs per HPD event) were identified. Human performance deficiencies were categorized as execution (98 HPDs [51.0%]), planning or problem solving (55 HPDs [28.6%]), communication (24 HPDs [12.5%]), teamwork (9 HPDs [4.7%]), and rules violation (6 HPDs [3.1%]). Human performance deficiencies most commonly presented as cognitive errors in execution of care or in case planning or problem solving (99 of 192 HPDs [51.6%]). In contrast, technical execution errors without other associated HPDs were observed in 20 of 192 HPDs (10.4%).
Conclusions And Relevance: Human performance deficiencies were identified in more than half of adverse events, most commonly associated with cognitive error in the execution of care. These data provide a framework and impetus for new quality improvement initiatives incorporating cognitive training to mitigate human error in surgery.
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http://dx.doi.org/10.1001/jamanetworkopen.2019.8067 | DOI Listing |
J Anesth
January 2025
Department of Anesthesiology, the First Affiliated Hospital, Sun Yat-sen University, No.58, Zhongshan 2Nd Road, Guangzhou, 510080, China.
Purpose: Perioperative respiratory adverse event (PRAE) is one of the most common complications in pediatric anesthesia. We aimed to evaluate the efficacy of perioperative pharmacological interventions to prevent the development of PRAE in children undergoing noncardiac surgery.
Methods: PubMed, Embase, Cochrane Library and ClinicalTrials.
Naunyn Schmiedebergs Arch Pharmacol
January 2025
University Clinic for Psychiatry and Psychotherapy, Brandenburg Medical School Immanuel Klinik Rüdersdorf, Seebad 82/83, Rüdersdorf bei Berlin, 15562, Rüdersdorf, Germany.
Sexual dysfunctions (SD) are common and debilitating side effects of antipsychotics. The current study analyzes the occurrence of antipsychotic-related SD using data from the US Food and Drug Administration (FDA) Adverse Event Reporting System (FAERS). FAERS was queried for sexual dysfunction adverse events (encoded by 35 different MedDRA preferred terms) secondary to amisulpride, aripiprazole, chlorprothixene, clozapine, haloperidol, loxapine, olanzapine, pipamperone, quetiapine, risperidone, and ziprasidone from 2000 to 2023.
View Article and Find Full Text PDFCVIR Endovasc
January 2025
Department of Radiology, Section of Vascular and Interventional Radiology, University of Washington, 1959 Northeast Pacific Street, Seattle, WA, 98195, USA.
Purpose: To evaluate access site adverse events following ClotTriever-mediated large-bore mechanical thrombectomy via small upper extremity deep veins (< 6-mm).
Materials And Methods: Twenty patients, including 24 upper extremity venous access sites, underwent ClotTriever-mediated large-bore thrombectomy of the upper extremity and thoracic central veins for symptomatic deep vein obstruction unresponsive to anticoagulation. Patients without follow-up venous duplex examinations (n = 3) were excluded.
Clin Transl Oncol
January 2025
Federal University of Pará, Belém, Pará, 66073-005, Brazil.
Background: The benefit of treatment with tyrosine kinase inhibitors targeting the epidermal growth factor receptor (EGFR-TKI) for lung adenocarcinoma (ADC), stratified by ethnicity, has not yet been fully elucidated.
Methods: We searched PubMed, Embase, and Cochrane databases for studies that investigated EGFR-TKI for lung ADC. We computed hazard ratios (HRs) or risk ratios (RRs) for binary endpoints, with 95% confidence intervals (CIs).
Diabetes Ther
January 2025
First Clinical Medical College, Shandong University of Traditional Chinese Medicine, Department of Endocrinology and Metabology, The First Affiliated Hospital of Shandong First Medical, University & Shandong Provincial Qianfoshan Hospital, Shandong Key Laboratory of Rheumatic Disease and Translational Medicine, Shandong Institute of Nephrology, Jinan, China.
Introduction: More than half of diabetes patients are Asians, and their tolerance to antidiabetic drugs may differ from that of non-Asians. Oral semaglutide has recently gained attention for its advantages in glycemic and body weight control. However, its effects across different ethnic groups remain unknown.
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