Researchers created a classification system in which they identified five categories of human performance deficiencies:
1. Planning or problem solving
2. Execution
3. Rules violation
4. Communication
5. Teamwork
Within these categories, subcategories were identified to further interpret the most common types of errors that were occurring. The researchers found that more than half of the human performance deficiencies were cognitive errors, such as lack of attention, lack of recognition and cognitive bias.
"Errors related to communication, teamwork and system-based errors were much lower than expected," said Dr. James Suliburk, associate professor of surgery at Baylor and first author of the paper. "This means our efforts to optimize communication, teamwork and system-related safety in our work culture have succeeded - the data suggests that further strategies for improvement of quality and safety based on system improvement may not solve the problem or be the greatest opportunity for improvement anymore."
Rosengart suggests the answer may be in cognitive training of medical staff to recognize cognitive pitfalls.
"Instead of adding another checklist, we want to train people to be more in touch with their vulnerability to human performance deficiency," he said. "We have to train people to listen to the voice in the back of their head."
Surgeons and researchers at Baylor College of Medicine plan to use the information collected in their study to create a simulation-training course focused on avoiding cognitive errors.
"We're taking a completely different approach. Humans are imperfect, but we can make them a little bit more perfect than they are now. We're not focusing exclusively on building more systems around humans, we're going to focus on the humans," Rosengart said.
Others involved in the study include Quentin M. Buck, Dr. Chris J. Pirko, Dr. Nader Masserweh, Dr. Neal Barshes and Dr. Hardeep Singh, all with Baylor College of Medicine.
Rosengart also holds the DeBakey-Bard Chair in Surgery at Baylor College of Medicine and operates at Baylor St. Luke's Medical Center, Harris Health System's Ben Taub Hospital and the Michael E. Debakey Veterans Affairs Medical Center. Suliburk operates at Baylor St. Luke's Medical Center and Harris Health System's Ben Taub Hospital.
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