Non-technical Errors, a Hidden Contributor to Patient Mortality in Emergency General Surgery: A National Retrospective Cohort Study.
Non-technical errors occurred in most emergency general surgery deaths reviewed.
Non-technical Errors, a Hidden Contributor to Patient Mortality in Emergency General Surgery: A National Retrospective Cohort Study.
Deficiencies in surgical non-technical skills (non-technical skills) contribute substantially to patient harm.
To characterize the incidence, clinical phase, team responsibility, and behavioral drivers of non-technical errors (non-technical errors) associated with death in emergency general surgery to inform future non-technical skills improvement strategies.
Retrospective cohort study including all emergency general surgical mortalities with an adverse event or area of concern from a national, mandated, peer-reviewed mortality audit (2012-2019).
Situational awareness errors occurred most (518/1053, 49.3%), followed by decision-making errors (431/1053, 40.9%).
Most errors arose from few recurring behaviors: for situational awareness, failure to recognize clinical signs (92/518, 17.8%), failure to appreciate illness severity (75/518, 14.5%), and missed diagnosis (73/518, 14.1%); for decision-making, failure to initiate appropriate intervention/investigation (99/431, 23%) or incorrect operation performed (71/431, 16.5%).
Non-technical errors associated with patient death predominantly occurred outside the operating theatre, arose from few recurrent behaviors, and involved surgical and non-surgical teams.
Future non-technical skills improvement strategies must extend beyond the theatre, be behaviorally informed, and target all teams involved.