Analysis of errors enacted by surgical trainees during skills training courses

doi:10.1016/j.surg.2005.02.014

Surgery

Volume 138, Issue 1, July 2005, Pages 14-20

https://doi.org/10.1016/j.surg.2005.02.014 Get rights and content

Background

Despite the emphasis on medical error as a major cause of hospital morbidity and mortality, there has been little published work on errors committed by trainees. This issue is particularly relevant to the training of surgeons and was addressed by our study.

Methods

Sixty simulated laparoscopic cholecystectomies performed on restructured pig tissue models by 60 surgical trainees provided the study material. The unedited videotapes were analyzed by observational HRA of the component steps of the procedures. Ten generic forms of observable error types were used to categorize patterns of failure. Error probabilities with specific instruments were also calculated.

Results

A total of 1067 errors were identified by observational HRA: 331 consequential and 736 without consequence (ie, total error rate of 18 [SD ± 10]) per procedure. The study documented a wide variation in the number of errors between the 60 trainee surgeons. The important underlying factors for the trainee errors were (1) omission of important steps, (2) execution of steps in the wrong sequence, and (3) use of excessive force. These 3 errors accounted for 92% of consequential errors.

Conclusions

This study has shown that trainees vary considerably in their propensity to commit errors. This variability indicates that the surgical training in component skills for laparoscopic surgery should be flexible and individualized. Three mechanisms account for the majority of errors and indicate that skills training in surgery has to be structured, menu driven, and tailored to individual needs.

Section snippets

Material and methods

HRA techniques were used to analyze 60 unedited video recordings by 60 surgical trainees performing simulated laparoscopic cholecystectomy on restructured animal tissue model developed by the CSC staff for this purpose. All the trainee surgeons performed these operations at the CSC as part of a basic skills training course in laparoscopic surgery.

Results

The mean execution time per simulated laparoscopic cholecystectomy was 38 ± 11 minutes. The analysis of the 60 procedures identified 1067 errors: 331 with consequences and 736 without. The mean (SD) of the total errors was 18 ± 10, whereas the mean of the consequential errors was 6 ± 7. There was a wide variation in the number of errors committed by the trainee surgeons (Fig 2).

The error probability for dissection of the cystic pedicle, division of the cystic artery and duct, and separation of

Discussion

This observational study used HRA techniques to identify and quantify errors enacted during basic skills training for laparoscopic surgery. Perhaps the most important finding was the wide variance in technical error rates between the 60 surgical trainees, indicating different levels of innate abilities for manipulative tasks. If the study sample is a fair representative of the initial skill level of surgical trainees, the results of our study imply that the training in laparoscopic skills

Conclusion

This study has shown that trainees vary considerably in their propensity to commit errors. This variability indicates that surgical training in component skills for laparoscopic surgery during in vitro laparoscopic training should be flexible and individualized. Three mechanisms account for the majority of errors, indicating that skills training in surgery has to be structured, menu driven, and tailored to individual needs.

References (24)

D.J. Scott et al.
Laparoscopic training on bench models: better and more cost effective than operating room experience?
J Am Coll Surg
(2000)
L.L. Leape
Institute of Medicine error figures are not exaggerated
JAMA
(2000)
C.D. Smith et al.
Assessing laparoscopic manipulation skills
Am J Surg
(2001)
A.I.M. Macmillan et al.
Assessment of innate ability and skills for endoscopic manipulation by the advanced Dundee endoscopic psychomotor tester:predictive and concurrent validity
Am J Surg
(1999)
P. Joice et al.
Errors enacted during endoscopic surgery—a human reliability analysis
Appl Ergo
(1998)
Directive 2000/34/EC of the European Parliament and Council
OJEC
(2000)
T. Pickersgill
The European working time directive for doctors in training
BMJ
(2001)
B.M. Wolfe et al.
Training for minimally invasive surgery: need for surgical skills
Surg Endosc
(1993)
G.M. Fried et al.
Comparison of laparoscopic performance in vivo with performance measured in a laparoscopic simulator
Surg Endosc
(1999)
P.L. Figet et al.
Transfer of training in acquiring laparoscopic skills
J Am Coll Surg
(2001)

The Southern Surgeons Club

A prospective analysis of 1518 laparoscopic cholecystectomy

N Engl J Med

(1991)

D.R. Fletcher et al.

Complications of cholecystectomy: risks of the laparoscopic approach and protective effects of operative cholangiography—a population based study

Ann Surg

(1999)

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: Supported by a grant from the Chief Scientist Office of Scotland (reference no. K/OPR/15/10/F16) to G. B. Hanna and A. Cuschieri.

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Original communicationAnalysis of errors enacted by surgical trainees during skills training courses

Background

Methods

Results

Conclusions

Section snippets

Material and methods

Results

Discussion

Conclusion

J Am Coll Surg

JAMA

Am J Surg

Am J Surg

Appl Ergo

Directive 2000/34/EC of the European Parliament and Council

OJEC

The European working time directive for doctors in training

BMJ

Training for minimally invasive surgery: need for surgical skills

Surg Endosc

Comparison of laparoscopic performance in vivo with performance measured in a laparoscopic simulator

Surg Endosc

Transfer of training in acquiring laparoscopic skills

J Am Coll Surg

A prospective analysis of 1518 laparoscopic cholecystectomy

N Engl J Med

Complications of cholecystectomy: risks of the laparoscopic approach and protective effects of operative cholangiography—a population based study

Ann Surg

Original communication
Analysis of errors enacted by surgical trainees during skills training courses