Error analysis in laparoscopic surgery

Iatrogenic complications in laparoscopic surgery, as in any field, stem from human error. In recent years, cognitive psychologists have developed theories for understanding and analyzing human error, and the application of these principles has decreased error rates in the aviation and nuclear power industries. The purpose of this study was to apply error analysis to laparoscopic surgery and evaluate its potential for preventing complications. Our approach is based on James Reason's framework using a classification of errors according to three performance levels: At the skill-based performance level, slips are caused by attention failures (eg, inattention, overattention), and lapses result from memory failures (eg, omitting, forgetting plans). Rule-based mistakes (eg, misapplication of, good rule or application of bad rule) constitute the second level. Knowledge-based mistakes occur at the highest performance level and are caused by shortcomings in conscious processing (eg, selectivity, workspace limitations, confirmation bias, overconfidence, inadequate training). These errors committed by the performer "at the sharp end" occur in typical situations which often times are brought about by already built-in latent system failures. We present a series of case studies in laparoscopic surgery (eg, bile duct injury during lap cholecystectomy, perforation during lap fundoplication) in which errors are classified and the influence of intrinsic failures and extrinsic system flaws are evaluated. Most serious technical errors in lap surgery stem from a rule-based or knowledge-based mistake triggered by cognitive underspecification due to incomplete or illusory visual input information. Error analysis in laparoscopic surgery should be able to improve human performance, and it should detect and help eliminate system flaws. Complication rates in laparoscopic surgery due to technical errors can thus be considerably reduced.