Contact Information:

Media Contact

Sharon Theimer
newsbureau@mayo.edu
507-284-5005

Twitter: MayoClinic

http://www.mayoclinic.org/news




Kredyty mieszkaniowe Kredyty mieszkaniowe

Sprawdź aktualny ranking najlepszych kredytów mieszkaniowych w Polsce - atrakcyjne kredytowanie nieruchomości.

PRESS-NEWS.org - Press Release Distribution
FREE PRESS RELEASES DISTRIBUTION
RSS - Press News Release
Add Press Release

How does human behavior lead to surgical errors? Mayo Clinic researchers count the ways

Four to nine factors contributed to each 'never event,' study finds


2015-06-01
(Press-News.org) ROCHESTER, Minn. -- Why are major surgical errors called "never events?" Because they shouldn't happen -- but do. Mayo Clinic researchers identified 69 never events among 1.5 million invasive procedures performed over five years and detailed why each occurred. Using a system created to investigate military plane crashes, they coded the human behaviors involved to identify any environmental, organizational, job and individual characteristics that led to the never events. Their discovery: 628 human factors contributed to the errors overall, roughly four to nine per event. The study results are published in the journal Surgery.

The never events included performing the wrong procedure (24), performing surgery on the wrong site or wrong side of the body (22), putting in the wrong implant (5), or leaving an object in the patient (18). All of the errors analyzed occurred at Mayo; none were fatal.

The Mayo Rochester campus rate of never events over the period studied was roughly 1 in every 22,000 procedures. Because of inconsistencies in definitions and reporting requirements, it is hard to find accurate comparison data, but a recent study based upon information in the National Practitioner Data Bank estimated that the rate of such never events in the United States is almost twice that in this report, approximately 1 in 12,000 procedures.

Nearly two-thirds of the Mayo never events occurred during relatively minor procedures such as anesthetic blocks, line placements, interventional radiology procedures, endoscopy and other skin and soft tissue procedures.

Medical teams are highly skilled and motivated, yet preventing never events entirely remains elusive, says senior author Juliane Bingener, M.D., a gastroenterologic surgeon at Mayo Clinic. The finding that factors beyond "cowboy-type" behavior were to blame points to the complexity of preventing never events, she says.

"What it tells you is that multiple things have to happen for an error to happen," Dr. Bingener says. "We need to make sure that the team is vigilant and knows that it is not only OK but is critical that team members alert each other to potential problems. Speaking up and taking advantage of all the team's capacity to prevent errors is very important, and adding systems approaches as well."

For example, to help prevent surgical sponges from being left in patients, Mayo Clinic installed a sponge-counting system and uses that bar code-scanning system and vigilance by the surgical team to track sponges. Other preventive systems include use of The Joint Commission health care quality organization's Universal Protocol, team briefings and huddles before a surgery starts, a pause before the first incision is made, and debriefings using a World Health Organization-recommended safety checklist.

To investigate the never events, the researchers used human factors analysis, a system first developed to investigate military aviation accidents. They grouped errors into four levels that included dozens of factors: "Preconditions for action," such as poor hand-offs, distractions, overconfidence, stress, mental fatigue and inadequate communication. This category also includes channeled attention on a single issue: In layman's terms, focusing so much on a tree that one cannot see the forest. Unsafe actions, such as bending or breaking rules or failing to understand. This category includes perceptual errors such as confirmation bias, in which surgeons or others convinced themselves they were seeing what they thought they should be seeing. Oversight and supervisory factors: Inadequate supervision, staffing deficiencies and planning problems, for example. Organizational influences: Problems with organizational culture or operational processes.

In addition to systems approaches and efforts to improve communication, attention should be paid to cognitive capacity, such as team composition, technology interfaces, time pressures and individual fatigue, the researchers say.

The stakes are high for patients, physicians and hospitals, Dr. Bingener says.

"The most important piece is the patient perspective. You don't want a patient to have to experience a never event. The breach in trust that happens with that is the most important part," she says.

INFORMATION:

The study was funded in part by National Institute of Diabetes and Digestive and Kidney Diseases grant K23DK93553. The research team included members of the Mayo Clinic Department of Surgery, the Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Quality Management Services and Pulmonary and Critical Care Medicine.

Disclosures: Dr. Bingener is supported through an NIDDK research grant, specified research through Nestle and Stryker Endoscopy, has received travel support from Intuitive Surgical, and serves on Titan Medical's Surgeon Advisory Board. Co-author Susan Hallbeck, Ph.D., receives grant funding from Stryker Endoscopy.

About Mayo Clinic Mayo Clinic is a nonprofit organization committed to medical research and education, and providing expert, whole-person care to everyone who needs healing. For more information, visit http://www.mayoclinic.org/about-mayo-clinic or http://newsnetwork.mayoclinic.org/.

MEDIA CONTACT: Sharon Theimer, Mayo Clinic Public Affairs, 507-284-5005, Email: newsbureau@mayo.edu


ELSE PRESS RELEASES FROM THIS DATE:

Zinc in the body may contribute to kidney stones

2015-06-01
New research on kidney stone formation reveals that zinc levels may contribute to kidney stone formation, a common urinary condition that can cause excruciating pain. The research found that zinc may be the core by which stone formation starts. The study, led by UC San Francisco, opens a new perspective into the cause of urinary stones and related diseases and might ultimately lead to the identification of new preventive and therapeutic approaches. The article appears in the scientific journal PLOS ONE. "The ultimate goal of our research team is to prevent kidney ...

Distant radio galaxies reveal hidden structures right above our heads

2015-06-01
TORONTO, ON [1 June 2015] - By observing galaxies billions of light-years away, a team of astronomers has detected tube-like structures mere hundreds of kilometres above the Earth's surface. "For over 60 years, scientists believed these structures existed but by imaging them for the first time, we've provided visual evidence that they are really there," said Cleo Loi of the ARC Centre of Excellence for All-sky Astrophysics (CAASTRO) at the University of Sydney and lead author of a paper published in Geophysical Research Letters last week. The astronomers--including ...

Study suggests breastfeeding may lower risk of childhood leukemia

2015-06-01
Breastfeeding for six months or longer was associated with a lower risk of childhood leukemia compared with children who were never breastfed or who were breastfed for a shorter time, according to an article published online by JAMA Pediatrics. Leukemia is the most common childhood cancer and accounts for about 30 percent of all childhood cancers. Still, little is known about its cause. Breast milk is meant to exclusively supply all the nutritional needs of infants and current recommendations include exclusively breastfeeding for the first six months of life to optimize ...

Is diabetes protective against amyotrophic lateral sclerosis?

2015-06-01
A study of patients in Denmark suggests that type 2 diabetes may be associated with a reduced risk for the fatal neurodegenerative disease amyotrophic lateral sclerosis (ALS), according to an article published online by JAMA Neurology. Recent reports have suggested a protective association between vascular risk factors, such as obesity or higher body mass index (BMI), higher cholesterol levels and hyperlipidemia with ALS incidence and survival. Patients with type 2 diabetes have, on average, higher BMI, elevated blood lipid levels and defective energy metabolism. However, ...

Virtually no effect of state policies on organ donation, transplantation

2015-06-01
Policies passed by states to encourage organ donation have had virtually no effect on rates of organ donation and transplantation in the United States, according to an article published online by JAMA Internal Medicine. The shortage of solid organs for transplant is a critical public health challenge in the United States. Since the late 1980s, states have enacted numerous policies to increase the organ supply. Researcher Erika G. Martin, Ph.D., M.P.H., of the Nelson A. Rockefeller Institute of Government and Rockefeller College of Public Affairs & Policy, University ...

Medical home intervention with shared savings shows quality and utilization improvements

2015-06-01
A three-year study of a 'medical home' intervention that paid bonuses to physician practices based on financial savings has shown significant improvements in quality and use of some medical services relative to comparison practices, according to a new RAND Corporation study. The study is the first published evaluation of a multipayer medical home intervention that featured shared savings for primary care practices. The results appear in the June 1 edition of JAMA Internal Medicine. By paying bonuses to participating practices based on reaching quality and spending benchmarks, ...

Researcher discovers metabolite of prostate cancer drug more effective at treating aggressive tumors

2015-06-01
Cleveland: Cleveland Clinic researchers have discovered for the first time that a metabolite of an FDA-approved drug for metastatic prostate cancer, abiraterone (Abi), has more anti-cancer properties than its precursor. The research will be published online June 1st in Nature. Cleveland Clinic researcher Nima Sharifi, M.D., found that abiraterone, a steroid inhibitor, is converted into the more physiologically active D4A (Δ4-abiraterone) in both patients and animal models with prostate cancer who take the drug. Furthermore, they found that D4A is more effective ...

Salk scientists reveal epigenome maps of the human body's major organs

Salk scientists reveal epigenome maps of the human bodys major organs
2015-06-01
For more than a decade, scientists have had a working map of the human genome, a complete picture of the DNA sequence that encodes human life. But new pages are still being added to that atlas: maps of chemical markers called methyl groups that stud strands of DNA and influence which genes are repressed and when. Now, Salk scientists have constructed the most comprehensive maps yet of these chemical patterns--collectively called the epigenome--in more than a dozen different human organs from individual donors (including a woman, man and child). While the methylation ...

New anti-microbial compounds evade resistance with less toxicity

2015-06-01
CHAMPAIGN, Ill. -- New compounds that specifically attack fungal infections without attacking human cells could transform treatment for such infections and point the way to targeted medicines that evade antibiotic resistance. Led by University of Illinois chemistry professor Martin D. Burke, a team of chemists, microbiologists and immunologists developed and tested several derivatives of the antifungal drug amphotericin B (pronounced am-foe-TARE-uh-sin B). They published their findings in the journal Nature Chemical Biology. Amphotericin B is doctors' last, best defense ...

Study explores reasons behind alcohol abuse in non-heterosexual women

2015-06-01
WASHINGTON, DC, June 1, 2015 -- Non-heterosexual women who feel a disconnect between who they are attracted to and how they identify themselves may have a higher risk of alcohol abuse, according to a new study led by Amelia E. Talley, an assistant professor in Texas Tech University's Department of Psychological Sciences. The study, titled "Longitudinal Associations among Discordant Sexual Orientation Dimensions and Hazardous Drinking in a Cohort of Sexual Minority Women," appears in the June issue of the Journal of Health and Social Behavior. It delves into the reasons ...

LAST 30 PRESS RELEASES:

How your brain decides blame and punishment -- and how it can be changed

Uniquely human brain region enables punishment decisions

Pinpointing punishment

Chapman University publishes research on attractiveness and mating

E-cigarettes: Special issue from Nicotine & Tobacco Research

Placental problems in early pregnancy associated with 5-fold increased risk of OB & fetal disorders

UT study: Invasive brood parasites a threat to native bird species

Criminals acquire guns through social connections

Restoring ocean health

Report: Cancer remains leading cause of death in US Hispanics

Twin study suggests genetic factors contribute to insomnia in adults

To be fragrant or not: Why do some male hairstreak butterflies lack scent organs?

International team discovers natural defense against HIV

Bolivian biodiversity observatory takes its first steps

Choice of college major influences lifetime earnings more than simply getting a degree

Dominant strain of drug-resistant MRSA decreases in hospitals, but persists in community

Synthetic biology needs robust safety mechanisms before real world application

US defense agencies increase investment in federal synthetic biology research

Robots help to map England's only deep-water Marine Conservation Zone

Mayo researchers identify protein -- may predict who will respond to PD-1 immunotherapy for melanoma

How much water do US fracking operations really use?

New approach to mammograms could improve reliability

The influence of citizen science grows despite some resistance

Unlocking secrets of how fossils form

What happens on the molecular level when smog gets into the lungs?

Using ultrasound to clean medical instruments

Platinum and iron oxide working together get the job done

Tiny silica particles could be used to repair damaged teeth, research shows

A quantum lab for everyone

No way? Charity's logo may influence perception of food in package

[Press-News.org] How does human behavior lead to surgical errors? Mayo Clinic researchers count the ways
Four to nine factors contributed to each 'never event,' study finds
Press-News.org is a service of DragonFly Company. All Rights Reserved.
Issuers of news releases are solely responsible for the accuracy of their content.