The American Journal of Surgery
Volume 193, Issue 6 , Pages 657-659 , June 2007

The quest for procedural safety: a suggested framework for the clinical study of operator-based technical errors during surgical procedures

  • John R. Clarke, M.D.

      Affiliations

    • Department of Surgery, Drexel University, 245 N. 15th Street, Philadelphia, PA 19102, USA
    • ECRI Institute, 5200 Butler Pike, Plymouth Meeting, PA 19462, USA
    • Corresponding Author InformationCorresponding author. 412 McClenaghan Mill Rd., Wynnewood PA 19096-1006. Tel.: +1-610-246-8764; fax: +1-610-834-1275

Received 3 August 2006 ,Revised 6 November 2006

References 

  1. Clarke JR, Spejewski B, Gertner AS, et al. An objective analysis of process errors in trauma resuscitations. Acad Emerg Med. 2000;11:1303–1310
  2. Bruley ME. Surgical fires: perioperative communication is essential to prevent this rare but devastating complication. Qual Saf Health Care. 2004;13:467–471
  3. Reason J. Combating omission errors through task analysis and good reminders. Qual Saf Health Care. 2002;11:40–44
  4. Sarker SK, Hutchinson R, Chang A, et al. Self-appraisal hierarchical task analysis of laparoscopic surgery performed by expert surgeons. Surg Endosc. 2006;20:636–640
  5. Bonjer HJ, Hazebroek EJ, Kazemier G, et al. Open versus closed establishment of pneumoperitoneum in laparoscopic surgery. Br J Surg. 1997;84:599–602
  6. Mayol J, Garcia-Aguilar J, Ortiz-Oshiro E, et al. Risks of the minimal access approach for laparoscopic surgery: multivariate analysis of morbidity related to umbilical trocar insertion. World J Surg. 1997;21:529–533

 The author is reimbursed for his work for ECRI and for the Pennsylvania Patient Safety Authority.

PII: S0002-9610(07)00166-3

doi: 10.1016/j.amjsurg.2006.11.013

The American Journal of Surgery
Volume 193, Issue 6 , Pages 657-659 , June 2007

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