Observational Clinical Human Reliability Assessment Research Articles

Surgical experience and identification of errors in laparoscopic cholecystectomy.

Surgical errors are acts or omissions resulting in negative consequences and/or increased operating time. This study describes surgeon-reported errors in laparoscopic cholecystectomy. Intraoperative videos were uploaded and annotated on Touch SurgeryTM Enterprise. Participants evaluated videos for severity using a 10-point intraoperative cholecystitis grading score, and errors using Observational Clinical Human Reliability Assessment, which includes skill, consequence, and mechanism classifications. Nine videos were assessed by 8 participants (3 junior (specialist trainee (ST) 3-5), 2 senior trainees (ST6-8), and 3 consultants). Participants identified 550 errors. Positive relationships were seen between total operating time and error count (r2 = 0.284, P < 0.001), intraoperative grade score and error count (r2 = 0.578, P = 0.001), and intraoperative grade score and total operating time (r2 = 0.157, P < 0.001). Error counts differed significantly across intraoperative phases (H(6) = 47.06, P < 0.001), most frequently at dissection of the hepatocystic triangle (total 282; median 33.5 (i.q.r. 23.5-47.8, range 15-63)), ligation/division of cystic structures (total 124; median 13.5 (i.q.r. 12-19.3, range 10-26)), and gallbladder dissection (total 117; median 14.5 (i.q.r. 10.3-18.8, range 6-26)). There were no significant differences in error counts between juniors, seniors, and consultants (H(2) = 0.03, P = 0.987). Errors were classified differently. For dissection of the hepatocystic triangle, thermal injuries (50 in total) were frequently classified as executional, consequential errors; trainees classified thermal injuries as step done with excessive force, speed, depth, distance, time or rotation (29 out of 50), whereas consultants classified them as incorrect orientation (6 out of 50). For ligation/division of cystic structures, inappropriate clipping (60 errors in total), procedural errors were reported by junior trainees (6 out of 60), but not consultants. For gallbladder dissection, inappropriate dissection (20 errors in total) was reported in incorrect planes by consultants and seniors (6 out of 20), but not by juniors. Poor economy of movement (11 errors in total) was reported more by consultants (8 out of 11) than trainees (3 out of 11). This study suggests that surgical experience influences error interpretation, but the benefits for surgical training are currently unclear.

Constructivist Grounded Theory to Establish the Relationship Between Technical Error and Adverse Patient Outcome: Modeling Technical Error and Adverse Outcomes.

Preventable intraoperative errors have the potential to lead to adverse events. Our objective was to build a conceptual model of the relationship between minute technical errors performed by the surgeon and adverse patient outcomes. We used constructivist grounded theory methodology to build a model for the avoidance of technical errors. We used the Observational Clinical Human Reliability Assessment system, which categorizes granular, technical intraoperative errors, as our conceptual framework. We iteratively interviewed surgeons from multiple adult and pediatric surgical specialties, refined our semi-structured interview, and developed a conceptual model. Our model remained stable after interviewing 11 surgeons, and we reviewed it with earlier interviewed surgeons. Our conceptual model helps us understand how technical errors can be associated with adverse outcomes and is applicable to a broad range of surgical steps. Each technical error is defined by a unique improper technical motion that without a compensatory response, it may lead to 1 or more discreet adverse outcomes. Our model includes 5 primary defenses against an adverse outcome, including perfect technique, recognizing imperfect technique, adequately correcting imperfect technique, recognizing an adverse event, and adequately compensating for an adverse event. It includes multiple examples of compensating for a technical error, resulting in a near miss. Our conceptual model suggests that adverse patient outcomes can be related to minute technical deviations in surgical technique and provides a basis to study these preventable errors. Our model can also be used to develop intraoperative strategies to prevent these technical surgical errors.

Accuracy and usefulness in assessing proficiency of the observational clinical human reliability assessment checklist of the open inguinal hernia repair procedure: A cross-sectional study.

The Observational Clinical Human Reliability Assessment (OCHRA) can be used to score errors during surgical procedures. To construct an OCHRA-checklist, steps, substeps, and hazards of a surgical procedure need to be defined. A step-by-step framework was developed to segment surgical procedures into steps, substeps, and hazards. The first aim of this study was to investigate if the step-by-step framework could be used to construct an accurate Lichtenstein open inguinal hernia repair (LOIHR) stepwise description. The second aim was to investigate if the OCHRA-checklist based on this stepwise description was accurate and useful for surgical training and assessment. Ten expert surgeons rated statements regarding the accuracy of the LOIHR stepwise description, the accuracy, and the usefulness of the LOIHR OCHRA-checklist (eight, seven, and six statements, respectively) using a 5-point Likert scale. One-sample Wilcoxon signed-rank test was used to compare the outcomes to the neutral value of 3. The accuracy of the stepwise description and the accuracy and usefulness of the OCHRA-checklist were rated statistically significantly higher than the neutral value of 3 (median 4.75 [5.00-4.00] with p=.009, median 5.00 [5.00-4.00] with p=.012, median 4.00 [5.00-4.00] with p=.047, respectively). The experts rated the OCHRA-checklist to be useful for the training (5.00 [5.00-4.00], p=.009), and assessment (4.50 [5.00-4.00], p=.010) of surgical residents. This preliminary study showed that the stepwise LOIHR description constructed using the step-by-step framework was found to be accurate. The LOIHR OCHRA-checklist developed using the stepwise description was also accurate, and particularly useful for the training and assessment of proficiency of surgical residents.

One Step at a Time: Step by Step Versus Continuous Video-Based Learning to Prepare Medical Students for Performing Surgical Procedures

The objective of this study was to compare the effects of cognitive load and surgical performance in medical students that performed the open inguinal hernia repair after preparation with step-by-step video-demonstration versus continuous video-demonstration. Hypothetically, the step-by-step group will perceive lower extraneous load during the preparation of the surgical procedure compared to the continuous group. Subsequently, fewer errors will be made in the surgical performance assessment by the step-by-step group, resulting in better surgical performance. In this prospective study, participants were randomly assigned to the step-by-step or continuous video-demonstration. They completed questionnaires regarding perceived cognitive load during preparation (10-point Likert scale). Their surgical performance was assessed on a simulation hernia model using the Observational Clinical Human Reliability Assessment. Erasmus University Medical Center, Rotterdam, the Netherlands. Participants included medical students who were enrolled in extracurricular anatomy courses. Forty-three students participated; 23 students in the step-by-step group and 20 in the continuous group. As expected, the step-by-step group perceived a lower extraneous cognitive load (2.92 ± 1.21) compared to the continuous group (3.91 ± 1.67, p = 0.030). The surgical performance was not statistically significantly different between both groups; however, in subanalyses on a selection of students that prepared for 1 to 2 hours, the step-by-step group made less procedural errors, 1.67 ± 1.11, compared to the continuous group, 3.06 ± 1.91, p = 0.018. Our results suggest that preparation using step-by-step video-based learning results in lower extraneous cognitive load and subsequently fewer procedural errors during the surgical performance. For learning purposes, demonstration videos of surgical procedures should be presented in a segmented format.

A High-Definition Video Teaching Module for Thyroidectomy Surgery

With the changing landscape of postgraduate surgical education to competency-based curricula, there emerges a need for alternative forms of training. Video teaching modules have been shown to be effective tools in surgical education, complementing traditional postgraduate curricula. There is a lack of validated modules described in the literature, specifically for teaching thyroidectomy. The primary objective of this study was to develop and validate a high definition video-based teaching module instructing thyroidectomy surgery to Otolaryngology-Head and Neck Surgery trainees. This prospective study included intermediate to senior Otolaryngology-Head and Neck Surgery residents. Each participant first performed a thyroid lobectomy, serving as the initial assessment. After a washout period of at least 3 weeks, each participant was given the teaching module. The 15-minute module was developed using a 3-camera system and detailed a step-by-step approach to the surgery. After exposure to the module, each trainee performed the same procedure. Recordings of both procedures were deidentified and reviewed by a blinded, independent evaluator. Scoring was done using the Observational Clinical Human Reliability Assessment (OCHRA) system. University of Alberta Hospital and Royal Alexandra Hospital, Edmonton, Alberta, Canada. A total of 6 intermediate to senior Otolaryngology-Head and Neck Surgery residents entered and completed the study. The mean error rate was 8.8 errors per procedure before module exposure and 4.5 errors per procedure after exposure, representing a 49% decrease in error occurrence (p < 0.05). The mean staff takeover event rate was 10.5 takeovers per procedure prior to module exposure and 5.0 takeovers per procedure after exposure, representing a 52% decrease in error occurrence (p < 0.05). High-definition video teaching modules are a useful complement to traditional surgical training. In a climate where new innovations for teaching thyroid surgery are needed, properly constructed and validated video teaching modules can serve as important tools in supplementing traditional surgical training.

Identification of technical errors and hazard zones in sleeve gastrectomy using OCHRA : "OCHRA for sleeve gastrectomy".

The sleeve gastrectomy is an example of minimally invasive surgery. It is important to determine the critical steps of the procedure in order to reduce complications and increase safety and efficiency. The aim of this study was to detect the key elements of the sleeve gastrectomy and find the potential hazard zones of the procedure. Bariatric department of a large teaching hospital in the Netherlands. A prospective clinical observation study was performed including 60 sleeve gastrectomy procedures. An expert panel determined the key steps, and two experts assessed the procedures systematically for technical errors according to the principles of Observational Clinical Human Reliability Assessment (OCHRA). A total of 213 technical errors have been made, and the majority were made during mobilization of the greater curvature and during stapling of the stomach. In 44.6%, errors had consequences and 96 additional actions were performed. There was a significant correlation between errors during opening of the lesser sac and postoperative complications, and between repositioning of the stapler and postoperative complications. In this study, the 13 key steps of the SG were defined, and OCHRA was considered a valuable assessment tool for surgical performance and potential hazard zones. Most consequential errors are made during dissection of the greater curvature and during stapling of the stomach. Errors during the start of mobilization of the greater curvature and repositioning of the stapler lead to longer duration of the procedure and are associated with a higher risk of postoperative complications.

High definition video teaching module for learning neck dissection

IntroductionVideo teaching modules are proven effective tools for enhancing student competencies and technical skills in the operating room. Integration into post-graduate surgical curricula, however, continues to pose a challenge in modern surgical education. To date, video teaching modules for neck dissection have yet to be described in the literature.PurposeTo develop and validate an HD video-based teaching module (HDVM) to help instruct post-graduate otolaryngology trainees in performing neck dissection.MethodsThis prospective study included 6 intermediate to senior otolaryngology residents. All consented subjects first performed a control selective neck dissection. Subjects were then exposed to the video teaching module. Following a washout period, a repeat procedure was performed. Recordings of the both sets of neck dissections were de-identified and reviewed by an independent evaluator and scored using the Observational Clinical Human Reliability Assessment (OCHRA) system.ResultsIn total 91 surgical errors were made prior to the HDVM and 41 after exposure, representing a 55% decrease in error occurrence. The two groups were found to be significantly different. Similarly, 66 and 24 staff takeover events occurred pre and post HDVM exposure, respectively, representing a statistically significant 64% decrease.ConclusionHDVM is a useful adjunct to classical surgical training. Residents performed significantly less errors following exposure to the HD-video module. Similarly, significantly less staff takeover events occurred following exposure to the HDVM.

Root cause analysis of internal hernia and Roux limb compression after laparoscopic Roux-en-Y gastric bypass using observational clinical human reliability assessment

BackgroundInternal hernia (IH) and Roux limb compression (RC) are recognized complications after retrocolic laparoscopic Roux-en-Y gastric bypass for obesity. The aim of the present study was to systematically identify the surgical technical errors leading to these complications. MethodsAn observational clinical human reliability assessment approach was used to analyze the operating videos of 3 groups: an IH group (n = 12), a Roux compression group (n = 13), and a control group (no complications, n = 21). Two investigators, unaware of the outcomes, reviewed all videos, using special rating software. All errors were categorized using the external error mode system and further described if a direct consequential error (e.g., bleeding) was found. ResultsAn analysis of data showed that, on average, more errors occurred in the complication groups than in the control group (IH 5.85, Roux compression 3.54, control .90, P < .001). The strongest differences were found for missing intermesenteric stitches on both sides of the Roux limb. Logistic regression analysis showed that a missed stitch between the mesentery of the Roux limb and the transverse mesocolon was an independent predictor for IH (B = 1.727, P = .025). No technical or consequential errors could be identified as responsible for RC. ConclusionThe observational clinical human reliability analysis is a useful method to identify operative failure. For retrocolic, retrogastric laparoscopic Roux-en-Y gastric bypass, a systematic approach for the closure of the transverse mesenteric window might prevent IH complications.

Proficiency-gain curve for an advanced laparoscopic procedure defined by observation clinical human reliability assessment (OCHRA)

There is no established method for defining when a surgeon reaches the proficiency plateau in performing a specific operation. The published literature refers to "learning curves" based on retrospective evaluation of operative time, conversion rates, morbidity etc., which lack objectivity and do not address individual human factors. A more useful study of the gain in proficiency by the individual surgeon for a particular operation may be obtained using observational clinical-human reliability assessment (OCHRA). Following an 8-month fellowship in advanced laparoscopic surgery, the surgeon M.T. performed, independently at his own hospital, a prospective series of 20 palliative bypass operations for advanced gastric or pancreatic cancer. Unedited videotapes of gastro-jejunostomy (GJ) or cholecysto-jejunostomy (CJ) were analyzed independently in the training institution by the OCHRA technique. For this surgeon proficiency in executing laparoscopic palliative bypass was reached after the 14th anastomosis when efficient execution (reduction in operative time) was accompanied by significant reduction in technical errors and improved economy of movement (reduction of the economy of movement index from 7-5 to 3-2). The majority of errors were enacted in component tasks associated with intracorporeal suturing. The declining incidence of these errors with experience was an integral component of the proficiency-gain curve. The important performance-shaping factors identified were: concentration lapses (n=1,321), misjudgments (n=209), poor camera work (n=193), fatigue (n=128), and impaired coordination (n=108). This study has confirmed that OCHRA can describe quantitatively the proficiency-gain curve for a laparoscopic operation and indicate the plateau stage when the individual surgeon attains maximal performance in the execution of a specific procedure.

Competence Assessment of Laparoscopic Operative and Cognitive Skills: Objective Structured Clinical Examination (OSCE) or Observational Clinical Human Reliability Assessment (OCHRA)

Competence Assessment of Laparoscopic Operative and Cognitive Skills: Objective Structured Clinical Examination (OSCE) or Observational Clinical Human Reliability Assessment (OCHRA)

Competence Assessment of Laparoscopic Operative and Cognitive Skills: Objective Structured Clinical Examination (OSCE) or Observational Clinical Human Reliability Assessment (OCHRA)

There is no agreed system that is acknowledged as the ideal assessment of laparoscopic operative and cognitive skills. A new approach that combines Objective Structured Clinical Examination (OSCE) and Observational Clinical Human Reliability Assessment (OCHRA) was developed and used to assess trainees' operative and cognitive skills during laparoscopic training courses. Performance of 60 trainees participating in 3-day essential laparoscopic skills training (cognitive and psychomotor) courses were assessed and scored using both OSCE and OCHRA. The study showed significant inverse correlations between the number of technical errors identified by OCHRA and the scores obtained by OSCE for individual tasks performed either by electro-surgical hook or laparoscopic scissors (r = -0.864 and r = -0.808, respectively). Significant differences between trainees were observed in relation to both overall OSCE scores and OCHRA parameters: execution time, total errors, and consequential errors (P < 0.001). OCHRA provides a discriminative feedback assessment of laparoscopic operative skills. OCHRA and OSCE are best regarded as complementary assessment tools for operative and cognitive skills. The present study has documented significant variance between surgical trainees in the acquisition of both cognitive and operative skills.

Reducing errors in the operating room

Technical operative errors cause surgical operative morbidity and adversely affect the clinical outcome of patients. Surgical proficiency thus underpins good and safe practice. In this context, standardization of endoscopic surgical operations and their execution are essential for the procurement and maintenance of quality assurance in endoscopic surgical practice. There is no clash between individual- (surgical proficiency) and system-based defense systems in the prevention of surgical errors--both underpin safe surgical practice. Although more human factors and surgical research are needed, it is possible to formulate and adopt a surgical error reduction system for endoscopic operations based on standardization of operations, surgical operative proficiency, and human reliability assessment and its related clinical counterpart, observational clinical human reliability assessment.

Identification and Categorization of Technical Errors by Observational Clinical Human Reliability Assessment (OCHRA) During Laparoscopic Cholecystectomy

Surgical operative performance benefits from analysis of the mechanisms underlying technical errors committed during surgery. Prospective study using the Observational Clinical Human Reliability Assessment (OCHRA) system and complete unedited videotapes of the operations. Three National Health Service hospitals within the United Kingdom. Two hundred consecutive patients with symptomatic gallstone disease. Elective laparoscopic cholecystectomy for symptomatic gallstone disease by surgeons, who were blind to the nature and objectives of the study, using their usual operative technique. Surgical consequential and inconsequential operative errors. The analysis of 38 062 steps of the 200 laparoscopic cholecystectomies performed by 26 surgeons identified 2242 errors. The mean +/- SD total, inconsequential, and consequential errors per surgical procedure were 11.0 +/- 8.0, 8.0 +/- 6.0, and 4.0 +/- 3.0, respectively. Dissection of the Calot triangle (second task zone of the operation) incurred more total errors (6.5 +/- 5.4) compared with the first (2.9 +/- 2.8, P<.001) and third (5.1 +/- 3.9, P<.05) task zones. This translated to a higher error probability (6.9% vs 3.5% for the first and 5.5% for third task zones). The combined sharp and blunt dissection method had fewer errors than the blunt/teasing dissection technique (9.45 +/- 7.6 vs 13.9 +/- 7.3, P<.001) although different surgeons were involved. The most serious consequences were encountered during dissection with the electrosurgical hook knife. This study has confirmed that the Observational Clinical Human Reliability Assessment system provides a comprehensive objective assessment of the quality of surgical operative performance by documenting the errors, the stage of the operation in which errors are enacted most frequently, and where these errors have serious consequences (hazard zones).