Systems approach to reduce errors in surgery

Reducing the number of medical errors significantly is the challenge for the coming decade. In medicine and in surgery, in particular, errors are traditionally treated as being committed by individuals. To reduce human errors, two approaches can be used: the person approach and the systems approach. In the systems approach, the operator is not blamed, but the system is analyzed in order to find the causes of errors. Furthermore, defenses are built into the system so that errors will not result in an adverse outcome anymore. This article aims to provide insight into the systems approach.

[1]  J. Reason.  Human error: models and management , 2000, BMJ : British Medical Journal.

[2]  A. Cuschieri,et al.  Errors enacted during endoscopic surgery--a human reliability analysis. , 1998, Applied ergonomics.

[3]  H. Stassen,et al.  Manipulation in laparoscopic surgery: overview of impeding effects and supporting aids. , 1999, Journal of laparoendoscopic & advanced surgical techniques. Part A.

[4]  J. Dankelman,et al.  Peroperative analysis of the surgical procedure , 2001, Surgical Endoscopy And Other Interventional Techniques.

[5]  Jens Rasmussen,et al.  Skills, rules, and knowledge; signals, signs, and symbols, and other distinctions in human performance models , 1983, IEEE Transactions on Systems, Man, and Cybernetics.

[6]  H. Stassen,et al.  Observation in laparoscopic surgery: overview of impeding effects and supporting aids. , 1999, Journal of laparoendoscopic & advanced surgical techniques. Part A.

[7]  Cornelis A. Grimbergen,et al.  Force transmission of laparoscopic grasping instruments , 1997 .

[8]  S. Guerlain,et al.  A systems approach to surgical safety , 2002, Surgical Endoscopy And Other Interventional Techniques.

[9]  J. Dankelman,et al.  Problems with laparoscopic instruments: opinions of experts. , 2001, Journal of laparoendoscopic & advanced surgical techniques. Part A.

[10]  Robert Dye,et al.  HUMAN PERFORMANCE CONSIDERATIONS IN THE USE AND DESIGN OF AIRCRAFT CHECKLISTS. , 1995 .

[11]  Hirsch S Ruchlin,et al.  The Role of Leadership in Instilling a Culture of Safety: Lessons from the Literature , 2004, Journal of healthcare management / American College of Healthcare Executives.

[12]  Marilyn Sue Bogner,et al.  Human Error in Medicine , 1995 .

[13]  A. Cuschieri,et al.  Medical errors, incidents, accidents and violations , 2003, Minimally invasive therapy & allied technologies : MITAT : official journal of the Society for Minimally Invasive Therapy.

[14]  D. Diamond,et al.  ATLS-based videotape trauma resuscitation review: education and outcome. , 1993, The Journal of trauma.

[15]  L. Kohn,et al.  To Err Is Human : Building a Safer Health System , 2007 .