OK, back to hospitals (you will be happy to know!) One of our surgeons recently gave me an article about types of errors made in surgery, with particular attention to bile duct injuries that occur during laparoscopic removal of gall bladders (cholecystectomies).
I don't think the article is generally available to the public. It is from the Annals of Surgery, Volume 237, Number 4, pages 460-469 and is entitled "Causes and Prevention of Laparoscopic Bile Duct Injuries". I quote the conclusions:
These data show that errors leading to laparoscopic bile duct injuries stem principally from misperception, not errors of skill, knowledge, or judgment. The misperception was so compelling that in most cases the surgeon did not recognize a problem. Even when irregularities were identified, corrective feedback did not occur, which is characteristic of human thinking under firmly held assumptions. These findings illustrate the complexity of human error in surgery while simultaneously providing insights. They demonstrate that automatically attributing technical complications to behavioral factors that rely on the assumption of control is likely to be wrong. Finally, this study shows that there are only a few points within laparoscopic cholecstectomy where the complication-causing errors occur, which suggest that focused training to heighten vigilance might be able to decrease the incidence of bile duct injury.
I don't know about you, but I think this is really fascinating. The article explains:
Mental procedures that solve problems by making use of uncertain, probabilistic information are called heuristic processes. Heuristics are normal, unconscious decision-making algorithms that work quickly and relatively effectively, but they do not always provide correct solutions. Visual perception is one example. The visual system implicitly makes plausible assumptions about the environment as it analyzes the imaging information being processed on its way towards the conscious mind. Because the assumptions are simplifications, visual perception provides an estimate of reality, not a replica.
...[I]nnate neurophysiological assumptions governing heuristic perception make the process vulnerable to the creation of false images. Our conscious minds are at the mercy of the subconscious heuristics. ....[P]erception of form can be faulty and beyond the individual's knowledge or control. This is central to the mechanism of bile duct injuries.
Think about this. We cannot be satisfied with avoiding only errors of skill, knowledge, and judgment -- arguably where we spend most time in surgical training. We need to understand enough about neurophysiology to devise mechanisms to avoid errors of misperception, as well. A powerful addition to the quality and safety agenda.